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DISEASIS   OF   THE   LIVER 


&C. 


LOXDOS  :     rniSTEO    BY 

SPOTTISWOODE    AXI)    CO.,    NEW-STUKKT    SQUAKB 

AND     I'ABLIAJIENT    STRKKT 


CLINICAL    LECTUEES 


ON 


DISEASES    OF    THE   LIVER 

JAUNDICE   AND    ABDOMINAL   DEOPSY 

INCLUCmG   THE   CEOONIAN   LECTUKES    ON 

FUNCTIONAL  DERANGEMENTS   OP  THE  LIVER  DELIVERED   AT  THE 

ROYAL    COLLEGE    OF    PHYSICIANS   EsT    1874 


BY 

CHARLES  ^UECHISON,  M.D.  LL.D.  F.E.S. 

FELLOW  OF  THE  ROYAL  COLLEGE  OP  PHTSICLUfS ;    PRESIDENT  OF  THE  PATHOLOGICAL  SOCIETY  OF 

LONDON ;    PHYSICIAN    AND    LECTURER    ON    THE    PRINCIPLES  AND    PRACTICE    OP    MEDICINE, 

ST.  THOMAS'S  HOSPITAL ;    VICE-PRESIDENT  AND   CONSULTING   PHYSICIAN,  LONDON 

FEVER  HOSPITAL;  AND  EXAMINER  IN  MEDICINE,  UN^^^;RSITY  OP  LONDON; 

FORMERLY   PHYSICIAN  ANT)    LECTURER   ON   MEDICEfE,   MIDDLESEX 

HOSPITAL,  AND  ON  MEDICAL  STAFF  OF  H.M.  BENGAL  ARMY 


SECOND    EDITION 


NEW    YORK 
WILLIAM    WOOD    AND    CO.,    PUBLISHERS 

27  GREAT  JONES  STREET 
1877 


•i 


.w 


TO 

WILLIAM   MUEEAY   DOBIE,    M.D. 

PHYSICIAN  TO  THE  CHESTEE  INFIEMAET 

THIS    WORK    IS    DEDICATED 

BY 

THE    AUTHOR 

IN    ADMIRATION    OF    HIS    TALENTS    AS    A    SCIENTIFIC    PHYSICIAN 
AND    IN    TOKEN    OF    A    FRIENDSHIP    OF    THIRTY    YEARS 


PREFACE 


THE     SECOND     EDITION. 


As  WAS  STATED  iu  tlie  first  edition,  these  Lectures  have  no 
pretension  to  be  a  systematic  treatise  on  Diseases  of  the 
Liver.  Their  sole  object  is  to  assist  the  student  and  prac- 
titioner in  the  diagnosis  and  treatment  of  these  maladies. 

The  favourable  reception  accorded  to  the  first  edition 
encourages  me  to  hope  that  the  work  answered  the  piurpose 
for  which  it  was  intended.  Five  years  have  now  elapsed 
since  the  last  copy  of  a  large  impression  was  disposed  of. 

The  delay  in  the  preparation  of  this  edition  has  been 
occasioned  by  other  avocations  of  a  literary  and  profes- 
sional character,  and  by  my  desire  to  include  the  results  of 
the  labours  of  my  contemporaries,  as  well  as  those  of  my 
matured  experience  derived  from  hospital  and  private  prac- 
tice. The  Lectures  have  been  in  great  measure  re- written. 
Of  the  96  cases  which  were  published  in  the  first  edition 
6  have  been  omitted,  and  in  this  edition  90  cases  appear  for 
the  first  time,  making  a  total  of  180,  Most  of  these  additional 
cases  have  been  the  subject  of  clinical  remarks,  which  have 
been  incorporated  with  the  original  Lectures.  The  wood- 
cuts have  been  increased  from  25  to  37. 


Vlll  PREFACE    TO    THE    SECOND    EDITION. 

To  the  twelve  Lectures  which  appeared  in  the  fii'st  edition 
a  fresh  Lecture  on  some  of  the  rarer  forms  of  enlargement  of 
the  liver  has  been  added  (Lect.  VIL),  and  likewise  the  three 
Croonian  Lectures  on  '  The  Functional  Derangements  of  the 
Liver,'  which  I  had  the  honour  of  dehvering  before  the 
Eoyal  College  of  Physicians  in  1874.  Although  some  of  the 
remarks  in  these  last  Lectures  must  be  regarded  as  merely 
suggestive,  and  subject  to  modification  with  the  advance  of  our 
knowledge  of  the  healthy  functions  of  the  liver,  yet,  from  the 
extensive  correspondence  with  my  medical  bretliren  which 
they  have  called  forth,  I  have  the  satisfaction  of  feeling  that, 
at  all  events  for  the  time,  they  meet  a  want  in  medical 
literature,  and  that  the  views  expressed  in  them  are  con- 
firmed by  the  observations  of  practical  men. 

79  WiBiroLE  Street,  London,  W. 
April  1877. 


PEEFACE 


THE     FIEST     EDITION. 


These  Lectures  were  originally  delivered  to  the  Students 
of  the  Middlesex  Hospital,  and  the  first  four  have  already, 
in  part,  appeared  in  the  pages  of  the  *  Lancet.'  It  is  hoped 
that  their  publication  in  the  present  form  may  be  useful, 
not  merely  to  those  for  whom  they  were  originally  written, 
but  likewise  to  other  members  of  the  Medical  Profession. 

It  is  not  their  object  to  set  forth  a  complete  account  of 
diseases  of  which  they  treat,  but  rather  to  put  prominently 
forward  the  characters  on  which  their  diagnosis  is  based, 
and,  in  particular,  to  point  out  the  diagnostic  import  of 
those  signs  and  symptoms — such  as  enlargement  of  the 
fiver,  jaundice,  dropsy,  and  pain — ^which  are  common 
to  many  different  hepatic  disorders,  but  the  precise  cause  of 
which  is  often  unrecognized. 

The  original  descriptions  have  in  many  instances  been 
illustrated  by  the  introduction  of  diagrams  showing  the 
altered  size  and  relations  of  the  diseased  organs.  With  the 
third  Lecture  has  been  incorporated  a  portion  of  the  matter 
contained  in  an  essay  on  'The  Dangers,  Diagnosis,  and 
Treatment  of  Hydatid  Tumours  of  the  Liver,'  which  was 


X  PREFACE    TO    THE    FIRST    EDITION. 

published  in  the '  Edinburgh  Medical  Journal '  for  December 
1865  ;  and  to  the  last  Lecture  have  been  added  the  results  of 
an  inquiry  into  the  pathological  consequences  of  gall-stones, 
commenced  many  years  ago,  and  part  of  which  appeared  in 
a  memoir  on  abdominal  fistulse,  published  in  the  '  Edinburgli 
Medical  Journal'  for  July  and  August  1857.  To  all  of  the 
Lectures  has  been  appended  a  history  not  only  of  those  cases 
on  which  each  Lecture  was  originally  founded,  but  of  others 
which  have  occurred  subsequently  and  been  the  subject  of 
clinical  remarks  in  the  wards.  These  histories  have  been 
condensed  from  notes  taken  at  my  dictation  by  my  clinical 
clerks,  whose  kind  and  ready  assistance  I  take  this  oppor- 
tunity of  acknowledging.  The  records  of  these  cases  will, 
it  is  believed,  be  useful  to  the  medical  practitioner  who  meets 
with  others  of  a  like  nature,  for,  as  the  founder  of  patho- 
logical anatomy  long  ago  observed  :  '  Nulla  est  alia  pro  certo 
noscendi  via,  nisi  quamplurimas  et  morborum  et  dissecti- 
onum  historias,  tuni  aliorum,  tum  proprias,  collectas  habere, 
et  inter  se  comparare.' — Morgagui,  de  Sed.  et  Causis  Morbor. 
Lib.  IV.  Prooemium. 


79  WiMPOLE  Stkeet,  Cavendish  Square,  W. 
June  1868. 


CONTENTS. 


LECTURE  I. 

ENLARGEMENTS    OP   THE    LIVER. 

PAGE 

Introductory  Remarks — Normal  Dimensions  and  Boundaries  of  the  Liver — 
Circumstances  under  which  Enlargement  of  the  Liver  is  simulated  and 
the  means  of  distinguishing  such  spurious  Enlargements :  1.  Congenital 
Malformations :  2.  Early  Life ;  3.  Rickets ;  4.  Tight  Lacing ;  5. 
Certain  Diseases  of  the  Cheat ;  6.  Tumours  &c.  between  the  Liver  and 
the  Diaphragm ;  7.  Abnormal  Conditions  of  the  Abdominal  Viscera ; 
8.  Abnormal  Conditions  of  the  Abdominal  Parietes — Cases  in  Illustra- 
tion       .............     1 

LECTURE  II. 

ENLARGEMENTS    OP   THE    LIVER. 

True  Enlargements  of  the  Liver:  Subdivision  into  painless  and  painful: 
I.  The  Waxy,  Lardaceous,  or  Amyloid  Liver ;  II.  The  Fatty  Liver ; 
III.  Simple  Hypertrophy 30 

LECTURE  III. 

ENLARGEMENTS    OF   THE    LIVER. 

IV.  Hydatid  Tumour 55 

LECTURE  IV. 

ENLARGEMENTS   OP   THE    LIVER. 

V.  Congestion.  VI.  Interstitial  Hepatitis.  VII.  Inflammation  of  the 
Bile-ducts.     VIII.  Obstruction  of  Common  Duct  ....  131 

LECTURE  V. 

ENLARGEMENTS    OF   THE    LIVER. 

IX.  Pyaemic  Abscesses.     X.  Tropical  Abscess ...  .        .  164 


Xll  CONTENTS. 

LEOTUEE  VI. 

ENLARGEMENTS   OF   THE    LIVER. 

PACK 

XI.  Cancer 208 

LECTURE  VII. 

ENLARGEMENTS   OF   THE    LIVER. 

XII.  Spindle-cell  Sarcoma;  XIII;  Myxoma;  XIV.  Epithelioma;  XV. 
Cystosarcoma ;  XVI.  Multilocular  Hydatid;  XVII.  Simple  Cysts; 
XVIII.  Tubercle  ;  XIX.  Lymphatic  Growths  ;  XX.  Enlargement  with 
Xanthelasma ;  XXI.  Enlargements  of  Gall-hladder         .         .         .         235 

LECTURE  Vra. 

CONTRACTIONS   OF   THE  LIVER. 

Conditions  simulating  Contraction  of  Liver — True  Contractions  ;  I.  Simple 
Atrophy ;  II.  Acute  or  Yellow  Atrophy ;  HI.  Chronic  Atrophy 
(Cirrhosis — Simple  and  Syphilitic  Induration — Red  Atrophy,  &c.)        .  253 

LECTURE  IX. 

JAUNDICE. 

Definition — Importance  of  recognising  Causes — Spui'ious  Jaundice;  1. 
Chlorosis ;  2.  Cancerous  Cachexia ;  3.  Malaria  and  Poisons ;  4.  Sub- 
conjunctival Fat;  5.  Icterus  Neonatoriun ;  6.  Addison's  Disease;  7. 
Exposure  to  Sun  ;  8.  Pigments  in  Urine  ;  9.  Feigned  Jaundice.  Phe- 
nomena of  Jaundice: — L  Localities,  &:c ;  2.  Secretions;  3.  Bitter 
Taste ;  4.  Derangements  of  Digestion ;  5.  Pruritus ;  6.  Cutaneous 
Eruptions ;  7.  Temperature  ;  8.  Pulse ;  9.  Ilfemorrhages ;  10.  General 
Debility  and  Annemia ;  11.  Yellow  Vision  ;  12.  Cerebral  Symptoms — 
Theory  of  Jaundice 310 

LECTURE  X. 

JAUNDICE. 

Classification  of  Causes  of  Jaundice — Jaundice  from  Obstruction  of  the 

BUe-duct 334 

LECTURE  XI. 

JAUNDICE. 

Jaundice  independent  of  Obstruction  of  the  Bile-duct — Diagnosis  of  the 
Causes  of  Jaundice 394 


CONTENTS.  Xlll 

LECTURE  XII. 

FLUID    IN   THE    PERITONEUM. 

PAGK 

Its  Signs — The  Conditions  whicli  Simulate  it,  and  how  to  distingiiisli  them : 
1.  Ovarian  Cyst;  2.  Hydatid  Cyst;  3.  Renal  Cyst;  4.  Distended 
Urinarj^  Bladder ;  5.  Pregnant  Uterus — Causes  of  Fluid  in  Peritoneum : 

I.  Acute  Peritonitis ;  II.  Tubercular  Peritonitis ;  HI.  Chronic  Peri- 
tonitis; rV.  Cancer;  V.  Colloid;  VI.  Simple  Dropsy:  1.  From 
Disease  of  Kidneys ;  2.  From  Disease  of  Heart  or  Lungs ;  3.  From 
Portal  Ohstruction 434 

LECTURE   XIII. 

A.  HEPATIC   PAIN. 

Simulated  by :  1.  Pleurodynia ;  2.  Intercostal  Neuralgia ;  3.  Pleurisy ; 
4.  Gastric  Dyspepsia ;  5.  Intestinal  Colic ;  6.  Renal  Colic — The 
Varieties  and  Causes  of  genuine  Hepatic  Pain      .....  482 

B.  GALL-STONES. 

Their  various  Consequences,  Symptoms,  and  Treatment      ....  487 

C.  ENLARGEMENTS    OF    GALL-BLADDEPw 
Their  Causes,  Clinical  Characters,  and  Treatment 523 

LECTURE  XIV. 

THE    CROONIAN    LECTURES    ON   FUNCTIONAL    DERANGEMENTS    OF   THE    LIVER. 

Notice  of  Doctor  Croone — Present  Notions  as  to  Functional  Derangements 
of  Liver  unsatisfactory— A.  Functions  of  the  Liver  in  Health.  Historical 
Sketch ;  Galen's  Views ;  Obsequies  of  Liver  by  Bartholin  ;  Modern 
Views  ;  Functions  of  Liver  Threefold  :    I.  Sanguification  and  Nutrition ; 

II.  Disintegration  of  Albuminous  Matter;  HI.  Secretion  of  Bile — 
Composition,  Origin,  Quantity,  and  Uses  of  Bile — b.  Functional  De- 
rangements of  Liver — Objections  to  Existing  Classification — Proposed 
Classification:  I.  Abnormal  Nutrition:  1.  Corpulence;  2.  Emaciation 
— A.  Deficiency  of  Bile  ;  B.  Diabetes ;  c.  Other  Varieties  of  Emaciation. 

II.  Abnormal  Elimination ;  Symptoms  of  Retained  Bile ;  Cholestearsemia  530 

LECTURE  XV. 

THE    CROONIAN   LECTURES    ON   FUNCTIONAL   DERANGEMENTS    OF    THE    LIVER. 

IH.  Abnormal  Disintegration  :  1.  Lithsemia ;  2.  Gout ;  3.  Urinary  Calculi ; 
4.  Biliary  Calculi ;  5.  Degenerations  of  the  ludneys  and  Albuminuria ; 
6.  Structural  Diseases  of  the  Liver ;  7.  Degenerations  of  Tissue 
throughout  Body  ;  8.  Local  Inflammations  ;  9.  'Constitutional  Diseases' 
— ^IV.  Derangements  of  Organs  of  Digestion  :  1.  Tongue ;  2.  Appetite ; 
3.  Taste ;  4.  Dyspepsia ;    5.  Constipation   and   Diarrhcea ;  6.  Vitiated 


XIV  CONTENTS. 

PAGE 

Stools ;  7.  Intestinal  Haemorrliage ;  8.  Hsemorrlioids ;  9.  Hepatic  Pain ; 
10.  Jaundice,  its  Patliology — V.  Derangements  of  the  Nervous  System : 
1.  Aching  Pains  in  Limbs;  2.  Burning  Patches;  3.  Neuralgia; 
4.  Cramps  ;  5.  Headache — Megrim ;  6.  Vertigo  ;  7.  Convulsions ;  8. 
Mania ;  9.  Paralysis ;  10.  Noises  in  Ears ;  11.  Sleeplessness ;  12. 
Depression  of  Spirits ;  13.  Irritability  :  14.  The  Typhoid  State    .         .  562 


LECTURE  XVI. 

THE    CROONIAN   LECTURES    ON    FUNCTIONAL    DERANGEMENTS    OF 
THE    LIVER. 

VI.  Derangement  of  the  Organs  of  Circulation :  1.  Palpitations  and 
Flutterings  of  the  Heart;  2.  Exaggerated  Pulsation  of  the  Large 
Arteries ;  3.  Irregularities  and  Intermissions  of  the  Pulse ;  4.  Feeble 
Circulation  ;  5.  Anasmia  ;  6.  Angina  Pectoris ;  7.  Venous  Thrombosis 
— VII.  Derangements  of  Organs  of  Respiration :  1.  Chronic  Catarrh 
of  Fauces ;  2.  Bronchitis ;  3.  Spasmodic  Asthma — VIII.  Derangements 
of  the  Genito-Urinary  Organs :  1.  Deposits  of  Lithic  Acid  and  Lithates 
in  Urine  ;  2.  Renal  Calculi ;  3.  Diseases  of  Kidneys ;  4.  Cystitis ;  5. 
Urethritis ;  6.  Chordee ;  7.  Orchitis — IX.  Abnormal  Conditions  of 
Skin:  1.  Eczema,  Lepra,  Psoriasis,  and  Lichen;  2.  Urticaria;  3.  Boils 
and  Carbuncles  ;  4.  Pigment-spots ;  5.  Xanthelasma  ;  6.  Pruritus — c. 
Causes  of  Functional  Derangements  of  the  Liver :  I.  Secondary.  1. 
Structural  Diseases  of  the  Liver ;  2.  Disorders  of  Stomach  and  Bowels ; 

3.  Diseases  of  the  Heart  and  Lungs ;  4.  Pyrexia — II.  Primary :  1. 
Errors  in  diet ;  2.  Deficient  supplj--  of  Oxygen ;  3.  High  Temperature ; 

4.  Nervous  influences ;  5.  Constitutional  Peculiarities  ;  6.  Poisons — D. 
Treatment  of  Functional  Derangements  of  the  Liver:  1.  Diet;  2. 
Free  Supply  of  Oxygen ;  3.  Diluents ;  4.  Baths ;  5.  Aperients — 
Cholagogues ;  6.  Alkalies ;  7.  Chlorine,  Iodine,  Bromine,  and  their 
Salts ;  8.  Mineral  Acids  ;  9.  Tonics  ;  10.  Opium. — Concluding 
Remarks 594 


APPENDIX 629 

INDEX 635 


LIST  OF  WOOD-ENGRAVINGS. 


Fia.  PAGE 

1.  Natural  positiou  of  the  Liver,  as  seen  after  removal  of  tlie  Anterior 

Wall  of  tlie  Ohest  and  Abdomen 2 

2.  Natural   position  of  the   Liver,  as  seen   after  tlie   removal   of  the 

Vertebrae  and  the  Posterior  Wall  of  the  Chest  and  Abdomen  .        .       3 

3.  Normal  area  of  Hepatic  Dulness,  viewed  anteriorly      ....       4 

4.  Normal  area  of  Hepatic  Dulness,  viewed  from  right  side       ...       5 
6.  Normal  area  of  Hepatic  Dulness,  viewed  posteriorly     ....       5 

6.  Apparent  enlargement  of  the  Liver  resulting  from  Tight-lacing    .         .       9 

7.  Area  of  dulness  caused  by  effusion  into  the  Right  Pleura,  depressing 

the  Liver         ...........     10 

8.  Displacement  of  the  Liver  downwards  by  extensive  effusion  into  the 

Pericardium    .         .         .         .         .         .         ,         ,         ,         .         ,11 

9.  Tumour  in  right  hypochondrium  caused  by  circumscribed   peritoneal 

effusion  between  Liver  and  Diaphragm     ......     24 

10.  Increased  area  of  Hepatic  and  of  Splenic  Dulness  from  Waxy  Disease, 

anterior  view  ..........  32 

11.  Increased  area  of  Plepatic  Dulness  from  Waxy  Disease,  lateral  view     .  32 

12.  Area  of  Hepatic  Dulness  in  a  case  of  Hydatid  Tumour  of  the  Liver      .  87 

13.  Area  of  Hepatic  Dulness  in  a  case  of  Hydatid  Tumour  of  the  Liver     .  89 

14.  Appearance  of  Abdomen  in  a  case  of  Multiple  Hydatid  Tumours  of 

Liver  and  Peritoneum     .        .        .        .         .        .        .         .        .103 

15.  Appearance  of  Abdomen  in  a  case  of  Multiple  Hydatid  Tumours  of 

Liver  and  Peritoneum     .         .         .         .         .         .         .         .         .106 

16.  Area  of  Hepatic  Dulness  in  a  case  of  Enlargement  of  the  Liver,  and 

Distension  of  the  Gall-bladder  from  obstruction  of  the  Common 
Bile-duct 163 

17.  Area  of  Hepatic  Dulness  in  a  case  of  Tropical  Abscess  of  the  Liver       .  193 

18.  Area  of  Hepatic  Dulness  in  a  case  of  Cancer  of  the  Liver     .         .         .  209 

19.  Microscopic  appearances  in  a  case  of  Fungating  Cancerous  Tumour 

of  the  Liver,   showing  transitional  forms  between  the  Glandular 
EpitheHum  and  '  Cancer-cells ' 230 

20.  Group  of  Spindle-cells  from  Tumour  of  Choroid  in  a  case  of  Spindle- 

cell  Sarcoma  of  Liver 238 

21.  Appearance  of  Liver  in  a  case  of  Spindle-cell  Sarcoma         .        .         .  239 

a 


XVI  LIST    OF   WOOD-ENGRAVINGS. 

FIG.  I'AOK 

22.  Microscopic  appearances  of  Spiudle-cell  Sarcoma  of  Liver    .        .        .  240 

23.  Area  of  Hepjitic  Dulness  in  a  case  of  Acute  Atrophy  of  the  Liver        .  260 

24.  Microscopic  needle-shaped  Oiystals  of  Tyrosin  adhering  in  bundles  and 

in  stellate  groups 264 

25.  Microscopic  globular  masses  composed  of  Rcicular  crystals  of  Tyrosin    .  264 

26.  Microscopic,  laminated,  crystalline  masses  of  Leucin     ....  264 

27.  Shows  the  hepatic   and  ascitic  Dulness  in  a  case  of  Cin'hosis  of  the 

Liver      .         > 278 

28.  Microscopic  crystalline  masses  of  Carbonate  of  Lime  from  the  Gall- 

bladder   308 

29.  Microscopic  appearances  of  the  Blood  in  a  case  of  Chronic  Atrophy  of 

the  Liver  with  Leukaemia        ........  308 

30.  Percussion-sounds  over  the  Abdomen  in  a  case  of  Ascites  from  Cirrhosis 

of  the  Liver 436 

3L  Percussion-sounds  over  the  Abdomen  in  a  case  of  Tumour  of  the  Left 

Ovary 437 

32.  Crystals  of  Glycocholate  of  Soda  from  the  bile  of  the  Ox      .        .         •  544 

33.  Glycocholate  and  Taurocholate  of  Soda  fi-om  the  bile  of  the  Ox    .         .  544 

34.  Crystalline  plates  of  Oholesterin 545 

35.  Laminated  crystalline  masses  of  Leucin        ......  563 

36.  Ciy^tals  of  TjTosin  adhering  in  bundles        ......  563 

37.  Globular  masses  composed  of  acicular  crystals  of  Tyrusiu      .         .         .  503 


TABLE   OF  CHEMICAL  EQUIVALENTS. 


Albuminoids  (Lieberkiilin) O^aHnjNigSOoa 

Excretin G,,TI,,,SO, 

Taurocliolio  acid OoeH^jNO^S 

Glycocholic  acid O^gH^gNOe 

Oholicacid O24H40O5 

Taurin OaH.NOgS 

Glycocin O2H5NO2 

Eili'^'i^i^ G.eiiAO, 

Biliverdin CieH.oN^Og 

Tyrosiu O9H11NO3 

Leucin G,B.,,m, 

Hippuric  acid O9H9NO3 

Xanthiu O^H^N^O., 

Cy3tiii OgH.NSOj 

Kreatin O^HgNgO^ 

Kreatinin O^H.NgO 

Uric  or  litHc  acid  . OgH^N^Oj 

Urea .         .         .        .         .  OH^N^O 

Oxalic  acid O2H2O4 

Starch 0,H,,0, 

Dextrin .  O^H^A 

Glycogen,  or  animal  starch     .......  OgHj^Og 

Cane-sugar Oi^H^jOu 

Glucose,  or  grape-sugar OgHjoOg 

Lactose,  or  milk-sugar OgHj^Og 

Inosite,  or  muscle-sugar OgHjoOg 

LaeTulose G^R^JO^ 

Oholesterin G^&^^fi 


Corrigenda. 

Page    60,  line  28,  for  Case  XCVI.  read  Case  XCII. 
„     142,    „    12,  for  Case  CLXXVI.  read  Case  CLXXVUI. 
„     156,    „      8,  omit  See  Case  CXXI. 
„     18;J,    „    1 8,  ./b?"  usually  ««.&«^!Ym^i3  occasionally. 
„     260,    „    10,  insert  at  end  of  paragraph  See  Lect.  XI.  p.  407. 


LECTUEE   I. 
ENLARGEMENTS  OF  THE  LIVER. 

INTRODUCTORY     REMARKS — NORMAL     DIMENSIONS     AND     BOUNDARIES     OF     THE     LITER 

CIRCUMSTANCES  UNDER  WHICH  ENLARGEMENT  OF  THE  LIVER  IS  SIMULATED,  AND 
THE  MEANS  OF  DISTINGUISHING  SUCH  SPURIOUS  ENLARGEMENTS  :  1.  CONGENITAL 
JLALFORMATIONS  ;  2.  EARLY  LIFE  ;  3.  RICK-ETS  ;  4.  TIGHT-LACING  ;  5.  CERTAIN 
DISEASES  OP  THE  CHEST  ;  6.  TUMOUR  BETWEEN  THE  LIVER  AND  DIAPHRAGM  ; 
7.  ABNORMAL  CONDITIONS  OF  THE  ABDOMINAL  VISCERA  ;  8.  ABNORMAL  CONDITIONS 
OF    THE    ABDOMINAL    PARIETES — CASKS    m    ILLUSTRATION. 

Gentlemen, — In  systematic  lectures  on  Medicine,  it  is  the 
custom  to  describe  in  detail  the  numerous  symptoms  which 
characterise  different  disorders.  It  requires,  however,  little  ex- 
perience to  discover  that  there  are  symptoms  and  signs  which 
are  common  to  many  diseases,  and  that  no  small  difficulty  is 
often  encountered  in  determining  to  which  of  its  many  sources 
a  particular  symptom  ought  to  be  referred.  Yet  this  deter- 
mination must  always  be  your  first  object  in  practice.  You 
must  never  rest  satisfied  with  treating  merely  a  symptom 
without  endeavouring  to  acquire  some  definite  notion  of  the 
local  or  general  disease  upon  which  it  depends.  In  all  cases  of 
disease  presenting  some  prominent  symptom,  you  ought  to  ask 
yourselves  two  questions:  1.  What  are  the  different  causes 
which  may  give  rise  to  the  symptom  in  question  ?  and  2. 
Which  is  the  most  probable  cause  in  the  individual  case  before 
you  ?  Not  until  you  have  given  a  satisfactory  reply  to  these 
enquiries  will  you  be  in  a  position  to  speak  with  any  confidence 
as  to  prognosis,  or  to  adopt  a  rational  method  of  treatment. 

To  no  class  of  maladies  are  these  remarks  more  applicable 
than  to  diseases  of  the  liver.  There  are  few  diseases  more 
difficult  to  discriminate,  and  perhaps  none  in  which  an  erro- 
neous diagnosis  is  oftener  made :  while  symptoms  depending 
upon  disease  of  the  stomach,  the  intestines,  or  the  kidneys,  or 
even  of  the  heart,  the  lungs,  or  the  brain,  are  constantly 
ascribed  to  derangements  of  the  liver.     It  will  be  my  object  in 

B 


2  ENLARGEMENTS    OP    THE    LIVEE.  lect.  i. 

these  lectures  to  point  out  to  you  the  chief  signs  and  symptoms 
resulting  from  hepatic  disease,  the  different  morbid  conditions 
from  which  each  of  them  may  arise,  the  rules  by  which  you 
must  be  mainly  guided  in  determining  the  precise  disease  in 
each  case,  and  the  conclusions  to  which  you  ought  in  this  way 
to  be  led  respecting  prognosis  and  treatment.  We  shall  com- 
mence, for  instance,  by  discussing  the  different  causes  of  En- 
largement of  the  Liver  ;  and  in  subsequent  lectures,  the  causes 
of  Atrophy  of  the  Liver,  of  Jaundice,  Hepatic  Pain,  Hepatic 
Dropsy,  &c.,  will  be  duly  considered. 

ENLAKGEMENTS   OF  THE  LIVER. 

Before  proceeding  to  consider  the  various  causes  of  true 
enlargement  of  the  liver,  it  is  necessary  to  have  an  accurate 
knowledge  of  its  normal  dimensions  and  boundaries,  and  also 
to  keep  in  view  certain  conditions  which  during  life  may 
simulate  enlargement. 


Fig.  1.     Natural  Position  of  the  Liver,  as  seen  after  removal  of  the  anterior  wall  of 
the  chest  and  abdomen.     Modified  from  JSibson's  Med.  Anatomy. 

A,  Liver,    b,  Ascending  colon,    c,  Transverse  colon.    D,  Descandinp  colon,    e,  Small  intestines. 
F,  Stomach,    o,  Heart,    ii,  Right  lung.    I,  Left  lung. 

Normal  situation  and  dimensions  of  the  liver. — The  liver  is 
situated  in  the  right  hypochondrium,the  convexity  of  the  right 


LBCT.  I.  NORMAL    DIMENSIONS    AND    BOUNDARIES.  3 

lobe  corresponding  to  the  concavity  at  the  base  of  the  right 
lung  with  the  diaphragm  interposed,  and  the  under  surface 
being  opposed  to  the  stomach  and  large  intestine,  the  right 
kidney  and  supra-renal  capsule.  The  convex  upper  surface 
projects  up  into  the  right  side  of  the  chest,  and  a  great  part  of 


Fig.  2.     Natiiral  Position  of  the  Liver,  as  seen  after  the  removal  of  the  posterior  wall 
of  the  chest  and  abdomen.     Modified  from  Sibson's  Med.  Anatomy. 

The  liver  is  covered  by  the  diaphragm,  beneath  which,  on  the  left  side  (b)  there  is  also  the  spleen  and 
a  portion  of  the  stomach.    A,  Eight  lobe  of  liver,    c,  Ascending  colon,    d,  Descending  colon. 

it  is  in  immediate  juxtaposition  with  the  ribs,  but  the  upper- 
most portion  (in  a  vertical  direction)  is  separated  from  the  wall 
of  the  chest  by  the  thin  lower  margin  of  the  right  lung.  (See 
fig.    1.)     Accordingly,   in   percussion   during    life,    the   upper 

B  2 


4  ENLARGEMENTS    OF    THE    LIVER.  lect.  i. 

margin  of  hepatic  dulness  may  be  said  to  be  twofold,  one 
boundary  limiting  the  region  where  the  organ  is  in  close  ap- 
proximation to  the  walls  of  the  chest,  and  where  the  dulness  is 
absolute,  the  other  corresponding  to  the  extreme  height  of  the 
liver,  and  including  the  space  where  it  is  overlapped  by  the  thin 
layer  of  lung,  and  where  the  sound  on  percussion  constitutes  a 
transition  from  the  hepatic  dulness  to  the  pulmonary  resonance. 
It  is  the  latter  which  is  usually  regarded  as  the  true  upper 
margin  of  the  liver  (fig.  3). 

There   is    a   peculiarity   in    the  upper  margin   of  hepatic 
dulness  which  is  of  some  practical  importance — namely,  that  it 


/       V 


Fig.  3.     Area  of  Hepatic  Diilness,  viewed  anteriorly. 
rt-O,  Riglit  mammary  line,    c-d,  Median  line,    e,  Fplenic  dulness.   /,  Cardiac  dulness. 


is  not  horizontal,  but  arched.  Commencing  posteriorly  about 
the  tenth  or  eleventh  dorsal  vertebra,  it  ascends  slightly 
towards  the  axilla  and  the  nipple,  and  then  again  descends 
gradually  towards  the  median  line  in  front.  The  arched  cha- 
racter of  the  upper  surface  of  the  liver  is  shown  in  the  annexed 
diagrams  (figs.  3,  4,  5). 

In  determining  the  upper  margin  of  hepatic  dulness  we 
must  trust  to  percussion  alone.  In  ordinary  cases  it  is  suffi- 
cient to  note  the  upper  limit  in  what  is  called  the  right  mam- 
mary line,  or  a  line  descending  perpendicularly  from  the  riglit 
nipple  (fig.  3).  Here,  in  a  healthy  adult,  the  true  ujiper  margin 
of  the  liver  is  situated  in  the  fifth  intercostal  space,  or  in  rare 
cases  behind  the  fifth  rib  or  in  the  fourth  space.     In  this  line, 


NORMAL   DIMENSIONS    AND    BOUNDARIES. 


5 


the  liver  is  overlapped  by  lung  to  tlie  extent  of  about  one  incb. 
But  in  all  cases  of  suspected  hepatic  disease,  the  upper  margin 
of  hepatic  dulness  ought  to  be  determined  in  its  entire  course. 
In  the  median  line  in  front,  it  usually  corresponds  to  the 
base  of  the  ensiform  cartilage,  or  rises  slightly  above  this. 
To  the  left  of  the  median  line  it  is  difficult  or  impossible  to 
define  the  upper  limit  of  hepatic  dulness  from  the  lower 
boundary  of  the  heart,  the  two  being  in  apposition,  but  a  line 
drawn  from  the  upper  margin  of  hepatic  dalness  in  the  median 
line  to  the  apex  of  the  heart  will  usually  correspond  to  the 
line  of  separation.     In  the  ricjht  axillary  line  (fig.  4),  or  a  line 


Fig.  4.     Area  of  Hepatic  Dulness,         Fig.  5.     Area  of  Hepatic  Dulness,  Tie^wed 
viewed  from  right  side.  posteriorly. 


a-h,  Eight  axillary  line. 


a-l.  Right  dorsal  line,  c,  Splenic  dulness.  d,  Left 
kidney,  e.  Right  kidney.  /,  Descending  colon. 
g.  Ascending  colou. 


falling  perpendicularly  from  the  centre  of  the  axilla,  the  upper 
margin  of  hepatic  dulness  corresponds  to  the  seventh  intercostal 
space,  or  more  rarely,  to  the  seventh  rib.  In  the  right  dorsal 
line,  or  a  line  falling  perpendicularly  from  the  lower  angle  of 
the  scapula  (when  the  arm  is  dependent),  it  corresponds  to  the 
ninth  intercostal  space,  or  the  ninth  rib  (fig.  5). 

The  lower  margin  of  hepatic  dulness  may  be  determined  by 


6  ENLARGEMENTS   OF   THE    LIVER.  lf.ct.  i. 

percussion,  and  also,  if  diseased,  by  means  of  palpation.  When 
healthy,  the  lower  margin  of  the  liver  cannot  be  distinctly  felt, 
except  in  the  epigastrium.  Even  when  the  organ  is  diseased, 
it  is,  as  a  rule,  less  easily  defined  than  the  upper  margin,  being 
often  obscured  by  a  distended  condition  of  the  stomach  or  intes- 
tines, or  by  fluid  in  the  peritoneum.  Hence  it  is  always  most 
satisfactorily  examined  when  the  stomach  is  empty,  and  after  the 
bowels  have  been  freely  moved.  The  liver  may  then  be  dis- 
tinguished from  the  intestines  by  the  greater  resistance  it  offers 
to  pressure  by  the  hand.  In  the  right  mammary  line,  the  lower 
margin,  in  health,  usually  corresponds  with  the  margin  of  the 
costal  arch,  or  is  half  an  inch  above  or  below  this ;  in  the  right 
axillary  line,  it  corresponds  to  the  tenth  intercostal  space ;  and 
in  the  right  dorsal  line,  to  the  twelfth  rib,  although  here  it  is 
usually  difficult  to  define  it  from  the  dulness  of  the  kidney. 
In  the  epigastrium,  the  lower  margin  of  the  right  and  left 
lobes  usually  descends  to  nearly  half-way  between  the  ensiform 
cartilage  and  the  umbilicus. 

The  ordinary  extent  of  hepatic  dulness,  in  an  adult  of 
average  size,  is  4  inches  in  the  right  mammary  line,  4h  or  5 
inches  in  the  right  axillary  line,  4  inches  in  the  right  dorsal 
line,  and  3  or  4  inches  in  the  median  line  anteriorly. 

But  it  must  not  be  forgotten  that,  even  in  the  same  indi- 
vidual, the  liver  is  constantly  liable  to  slight  alterations  in  its 
position  consistently  with  health.  During  the  act  of  inspira- 
tion the  whole  organ  is  slightly  lowered — about  half  an  inch — 
and  its  upper  surface  is  somewhat  flattened,  whereas  during 
expiration  the  organ  ascends.  Again,  in  the  erect  position, 
the  lower  margin  will  extend  somewhat  lower  than  when  the 
patient  is  recumbent.  If  in  the  mammary  line  it  correspond  to 
the  lower  margin  of  the  costal  arch  in  the  latter  position,  it 
may  be  a  half  or  a  quarter  of  an  inch  lower  in  the  former. 
These  variations  however  are  slight,  and  are  not  likely  to  em- 
barrass the  diagnosis. 

But  difficulties  in  diagnosis  may  sometimes  arise  from  the 
boundaries  of  the  liver,  as  above  defined,  being  greatly  ex- 
ceeded without  any  real  enlargement  of  the  organ.  After 
death  it  is  often  found  that  a  liver  which  during  life  had  been 
thought  to  be  greatly  enlarged  is  even  smaller  than  it  ought 
to  be.  Hence,  in  all  cases  of  suspected  enlargement  of  the 
liver  it  is  important  to  keep  in  view  the  possibility  of  its  being 
of  a  spurious  character. 


SPURIOUS    ENLAEG-EMENTS. 


CIRCUMSTANCES    UNDER    WHICH    ENLARGEMENT    OF    THE    LIVER 
IS    SIMULATED    DURING    LIFE. 

The  cliief  of  these  conditions  are  the  following : — 

I.  Congenital  wialformations,  &c. — In  rare  cases,  in  conse- 
quence of  congenital  malformation,  the  liver  is  more  square  or 
globular  than  natural,  and  a  larger  portion  of  it  is  in  apposi- 
tion to  the  abdominal  and  thoracic  wall.  In  other  cases  the 
left  lobe  is  proportionately  large,  as  in  the  foetus.  In  cases 
of  still  greater  rarity  the  liver  is  protruded  into  the  right  side 
of  the  chest  through  an  opening  in  the  diaphragm,  which  may 
be  congenital,  or  the  result  of  accident.  Not  long  ago  a  case 
came  under  my  notice,  where,  owing  apparently  to  an  opening 
in  the  diaphragm  of  long  standing,  the  greater  portion  of  the 
right  lobe  of  the  liver  was  lodged  in  the  right  pleura,  and  the 
hepatic  dulness  in  consequence  ascended  as  high  as  the  third 
rib.  The  particulars  of  the  case  will  be  found  in  the  Patho- 
logical Society's  Transactions  (vol.  xvii.  p.  164).  The  diagno- 
sis of  such  conditions  during  life  must  of  course  always  be 
difficult,  and  will  rest  mainly  on  the  following  conditions  : — 

1 .  The  absence  of  any  symptom  indicative  of  disease  of  the 
liver. 

2.  The  absence  of  other  circumstances  likely  to  produce 
spurious  enlargement. 

3.  The  fact  of  the  increased  hepatic  dulness  persisting 
from  early  life  (except  in  diaphragmatic  hernia  resulting  from 
accident). 

II.  Early  life. — The  liver  is  proportionally  much  larger  in. 
infancy  and  adolescence  than  in  adult  life.  The  organ  does 
not  grow  in  proportion  to  the  rest  of  the  body.  In  the  adult 
the  average  weight  of  the  liver  is  one-fortieth  of  that  of  the 
entire  body,  whereas  previous  to  puberty  it  may  be  as  much  as 
one-thirtieth,  or  even  one-twentieth.  The  dimensions  vary 
accordingly,  so  that  the  upper  margin  of  hepatic  dulness  is 
often  higher  in  the  child  than  in  the  adult,  and  the  lower 
margin  descends  below  the  costal  arch  in  the  right  mammary 
line.  It  follows,  therefore,  that  an  extent  of  hepatic  dulness 
which  in  the  adult  would  be  abnormal,  may  be  perfectly  nor- 
mal in  the  child.  In  the  wards  of  the  hospital  I  have  had 
frequent  opportunities  of  pointing  out  to  you  this  peculiarity 
of  the  liver  in  early  life. 


8  ENLAEGEMENTS    OF   THE    LIVEE.  lect.  i. 

III.  Rickets,  causing  lateral  distortion  of  the  spine,  and 
the  deformity  known  as  the  '  pigeon  breast,'  may  lead  to  appa- 
rent enlargement  of  the  liver,  owing  to  the  organ  being  de- 
pressed and  elongated  in  its  vertical  diameter  from  lateral 
compression.  The  resemblance  to  hepatic  enlargement  may 
be  further  increased  by  there  being  a  disproportionate  reces- 
sion of  the  ribs  immediately  above  the  liver,  as  the  result  of 
which  there  is  an  apparent  bulging  of  the  hepatic  region. 
Hence,  in  lateral  distortion  of  the  spine  and  in  the  *  pigeon 
breast,'  care  must  be  taken  not  to  arrive  at  any  hasty  conclu- 
sion as  to  enlargement  of  the  liver. 

IV.  The  'practice  of  tight-lacing  may  cause  displacements 
and  malformations  of  the  liver,  which  may  simulate  enlarge- 
ment, and  give  rise  to  difficulties  in  diagnosis.  Tight-lacing 
may  act  on  the  liver  in  three  ways,  according  to  the  situation, 
the  tightness,  and  the  duration  of  the  constricting  cause. 

a.  The  liver  may  be  displaced  upwards  or  downwards, 
according  as  the  pressure  is  applied  below  or  above  the  organ. 
The  precise  situation  where  the  pressure  is  applied  will  vary 
with  the  prevailing  fashion  of  dress ;  but  most  commonly  in 
this  country  the  displacement  is  downwards,  and  this  may  be 
to  such  an  extent  that  the  lower  margin  of  the  liver  reaches 
the  ilium,  and  the  organ  appears  to  fill  up  the  whole  of  the 
right  side  and  front  of  the  abdomen  (fig.  6). 

h.  In  consequence  of  lateral  compression,  the  liver  may  be 
elongated  in  its  vertical  diameter,  so  that  a  larger  portion  of 
it  is  brought  into  apposition  with  the  abdominal  and  thoracic 
walls.  This  is  a  very  common  result  of  tight-lacing  (fig.  6). 
The  narrower  the  lower  portion  of  the  chest,  the  greater  will 
be  the  extent  of  liver  opposed  to  the  thoracic  and  abdominal 
walls. 

c.  When  the  pressure  is  exerted  by  a  tight  cord,  it  may 
produce  deep  fissures  in  the  substance  of  the  liver,  as  the  result 
of  which  portions  of  the  organ  may  be  more  or  less  detached, 
and  may  be  felt  as  movable  tumours  separated  from  the  he- 
patic dulness  by  tympanitic  portions  of  bowel. 

Apparent  enlargements  of  the  liver  from  tight-lacing  are 
far  more  common  than  is  generally  believed.  You  cannot 
pay  many  visits  to  the  post-mortem  room  without  observing 
examples  of  this  malformation,  which  accounts  for  not  a  few 
movable  tumours  in  the  abdomen  that  are  a  source  of  anxiety 
both   to  the  j)atient  and  the  medical  attendant.     Moreover, 


LKCT.  J.  SPUKIOUS   ENLARGEMENTS.  9 

tliese  acquired  malformations  of  the  liver,  although  most 
common  in  females,  are  occasionally  observed  in  the  male  sex. 
I  show  you  here  the  liver  of  a  man  with  a  deep  furrow,  from 
indentation  of  the  ribs,  which  resulted  apparently  from  the 
practice  of  wearing  a  very  tight  belt.  I  may  also  call  your 
attention  to  the  case  of  a  man,  aged  23,  lately  under  your 


Fig.  6,  Apparent  enlargement  of  the  Liver  resulting  from  Tight-lacing.  Modified 
from  Frerichs.  The  Liver  is  depressed,  and  its  vertical  diameter  elongated.  A 
deep  transverse  furrow  corresponds  to  the  site  of  constriction. 


observation  in  the  hospital,  with  a  firm  movable  tumour  in 
the  epigastrium,  which  there  was  reason  to  believe  was  a 
portion  of  the  liver  partially  detached  from  a  similar  cause. 

Apparent  enlargements  of  the  liver  from  tight-lacing  may 
usually  be  recognised  by  the  following  characters : — 

1.  Evident  signs  of  tight-lacing  in  the  walls  of  the  chest 
and  abdomen. 

2.  Occasionally  the  existence  of  a  distinct  transverse  fur- 
row in  the  substance  of  the  liver,  appreciable  through  the 
abdominal  parietes  on  palpation. 


10 


ENLARGEMENTS    OP    THE    LIVER. 


3.  The  absence  of  symptoms  of  disease  of  the  liver,  or  of 
serious  disease  in  the  chest  or  abdomen. 

4.  In  the  case  of  movable  tumours  from  tight-lacing,  their 
situation  and  the  absence  of  any  evidence  of  hydatid  tumour 
or  of  disease  of  the  gall-bladder  will  assist  the  diagnosis. 

V.  Certain  diseases  in  the  chest  may  cause  great  dei^ression 
of  the  liver  into  the  abdominal  cavity,  and  lead  to  the  idea 
that  the  organ  is  enlarged.  This  remark  ap^jlies  particularly 
to  extensive  effusion  into  the  right  pleural  cavity,  or  to 
pneumothorax  on  the  right  side.  In  these  affections  the 
natural  convexity  uj)wards  of  the  diaphragm  may  be  reversed, 
and  the  lower  margin  of  the  liver  may  descend  to  the  umbili- 
cus (fig.   7).      Depression  to   a   less  extent   may   result  from 


Fig.  7.     Effusion  into  the  Eight  Pleura  depressing  the  Livor. 

a,  Hepatic  dulness.  b,  Dulness  from  pleuritic  effusion  causing  bulging  of  the  right  side  of  chest,  and 
displacing  the  heart  to  the  left ;  its  upper  margin  horizontal,  c,  Cardiac  dulness.  d,  bplenic 
dulucss. 

intra-thoracic  tumours,  effusion  into  the  left  pleura  or  into 
the  pericardium  (fig.  8),  or  a  dilated  heart;  and  even  in 
pulmonary  emphysema  and  acute  pneumonia  '  the  liver  may 

'  See  a  ease  of  acute  pneumonia  of  the  right  lung,  referred  to  by  Dr.  Stokes  in  his 
work  on  '  Diseases  of  tiie  Heart  and  Aorta,'  p.  453.  '  So  great  was  the  enlargement 
of  tlie  lung  that  the  di;ip]iragni  and  liver  were  pushed  far  down  into  the  alidominal 
cavity.'  Dr.  bright  speaks  of  disj)laceme)it  of  the  liver  downwards  hy  pneumonic 
consolidation  as  a  frequent  occurrence  (Abdom.  Tumours,  Syd.  Soc.  ed.,  p.  255) ;  but 
Stokes  regards  it  as  exceptional,  and  this  also  is  tlie  result  of  my  own  oliservation. 
In  extensive  pneumonia,  however,  the  liver  is  usually  more  or  less  congested,  and  en- 
larged accordingly. 


SPURIOUS    ENLARGEMENTS. 


II 


be  lowered  to  the  extent  of  an  inch  or  more.  A  dilated  heart 
causes  great  depression  of  the  liver  far  oftener  than  is  com- 
monly believed  ;  not  unfrequently  from  this  cause  the  rounded 
upper  surface  of  the  liver  becomes  visible  through  the  abdo- 
minal parietes  below  the  ribs.  In  all  cases,  however,  where 
the  liver  is  depressed  in  consequence  of  disease  in  the  chest, 


Fig.  8.     Displacement  of  the  Liver  downwards  by  extensive  Effasion  into  the  Peri- 
cardium :  after  Sibson. 
A,  Liver,    b,  Pericardium  greatly  distended  ■n-ith  fluid. 


the  descent  of  its  lower  margin  is  probably  due  to  a  combina- 
tion of  causes  ;  for  when  there  is  disease  in  the  chest  sufficient 
to  depress  the  diaphragm,  there  is  usually  also  congestion  with 
slight  enlargement  of  the  liver. 

Apparent  enlargements  of  the  liver  from  the  causes  now 
referred  to  have  the  following  distinguishing  features  :  — 

1.  A  previous  history  of  pleurisy,  pericarditis,  bronchitis 
and  emphysema,  pneumonia,  chronic  cardiac  disease,  or  of 
phthisis  ending  in  pneumothorax.     At  the  same  time  it  is  well 


12  ENLARGEMENTS   OF   THE    LIVER.  lect.  i. 

to  remember  tliat  extensive  effusion  sometimes  takes  place  into 
the  pleura  in  a  very  latent  manner. 

2.  A  degree  of  dyspnoea  far  greater  than  would  be  ac- 
counted for  by  the  amount  of  enlargement  of  the  liver,  even  if 
real. 

3.  The  physical  signs  of  the  various  thoracic  diseases 
above  referred  to.  In  the  case  of  emphysema  and  pneumo- 
thorax, there  is  no  difficulty  in  defining  the  upper  margin  of 
the  liver,  and  in  ascertaining  that  the  extent  of  hepatic  dulness 
is  not  increased,  so  that  percussion  will  at  once  reveal  the 
nature  of  the  case.  The  signs  of  dilated  heart  also  are  usually 
sufficiently  clear.  But  in  pleurisy  it  may  be  impossible  to 
say  where  the  dulness  of  the  pleuritic  effusion  ends  and  the 
hepatic  dulness  begins ;  and  here,  as  in  some  forms  of  true 
hepatic  enlargement,  there  may  be  bulging  of  the  ribs  and 
obliteration  of  the  intercostal  spaces  (Cases  I.  II.).  Under 
such  circumstances  there  are  several  characters  of  considerable 
importance  in  diagnosis — viz. : 

a.  The  bulging  of  the  side  of  the  chest  is  more  uniform  in 
pleurisy,  and  not  abruptly  limited  to  the  lower  part,  as  in 
diseases  of  the  liver.  An  empyema,  however,  may  be  so  cir- 
cumscribed that  the  bulging  is  restricted  to  the  lower  part  of 
the  chest.     (See  Case  I.) 

h.  In  pleuritic  effusion,  the  upper  margin  of  the  dull  space 
is  horizontal  (fig.  7),  instead  of  arched  as  in  enlargements  of 
the  liver. 

c.  In  pleuritic  effusion,  the  upper  level  of  the  dull  space 
will  often  be  found  to  vary  with  the  position  of  the  patient. 
In  enlargement  of  the  liver,  it  is  the  same  in  all  positions. 

d.  In  pleuritic  effusion,  the  lower  margin  of  the  liver  does 
not  ascend  and  descend  with  expiration  and  inspiration,  which 
is  the  case  in  enlargements  of  the  liver,  unless  there  be  firm 
adhesions  to  the  abdominal  wall. 

e.  Eversion  of  the  lower  costal  cartilages  would  indicate 
hepatic  enlargement,  rather  than  pleuritic  effusion.  (But  see 
Case  II.). 

/.  When  there  is  sufficient  effusion  into  the  pleura  to  cause 
downward  bulging  of  the  diaphragm,  a  depression  may  be 
sometimes  observed  between  the  lower  margin  of  the  ribs  and 
the  upper  surface  of  the  liver,  which  is  not  met  with  in  hyper- 
trophy of  the  liver. 

Effusion  into  the  pericardium  wiU   be   recognised  by  the 


LECT.  I.  SPURIOUS    ENLARGEMENTS.  1 3 

outline  of  the  area  of  dulness  on  percussion.     It  is  the  left  lobe 
of  the  liver  that  is  mainly  displaced  by  it. 

In  arriving  at  a  diagnosis,  it  must  not  be  forgotten  that 
inflammation  of  the  pleura  or  of  the  base  of  the  right  lung 
may  coexist  with  real  enlargement  of  the  liver.  This  is  a  not 
uncommon  occurrence  in  hydatid  tumours  or  abscesses  of  the 
liver,  and  often  precedes  their  bursting  upwards  through  the 
diaphragm.  So  also  after  a  hydatid  tumour  of  the  liver 
has  burst  into  the  pleura,  extensive  empyema  may  coexist 
with  great  enlargement  of  the  liver.  I  shall  hereafter  have  an 
opportunity  of  bringing  under  your  notice  the  particulars  of 
cases  in  which  this  occurred. 

VI.  A  tumour  or  collection  of  fluid  hetween  the  wpjper  surface 
of  the  liver  and  the  diai^hragm,  or  in  the  substance  of  the  diaphragm, 
may  also  cause  great  depression  of  the  liver  and  apparent  en- 
largement of  the  organ.  The  upper  margin  of  dulness  may 
then  be  arched,  and  it  may  be  impossible  during  life  to  dis- 
tinguish the  case  from  one  of  real  enlargement  of  the  liver. 
Tou  will  find  a  case  recorded  by  the  late  Dr.  Bright,  where  a 
large  abscess  situated  between  the  diaphragm  and  the  liver 
produced  apparent  enlargement  of  the  liver  ;  ^  and  more  than 
once  I  have  l^nown  enlargement  of  the  liver  simulated  by  an 
encysted  collection  of  peritoneal  fluid  between  the  liver  and  the 
diaphragm,  when  the  organ  was  in  reality  atrophied.  Such 
cases,  however,  are  rare.  Case  V.  is  an  interesting  example  of 
this  difiiculty  in  diagnosis. 

VII.  Various  abnormal  conditions  of  the  abdominal  viscera 
may  displace  the  liver  upwards,  so  that  it  encroaches  upon  the 
cavity  of  the  chest  and  appears  to  be  enlarged.  This  happens 
not  unfrequently  in  cases  of  ascites,  and  in  ovarian  and  uterine 
tumours,  in  aneurism  of  the  abdominal  aorta,^  &c.  ;  and  hence 
elevation  of  the  liver  above  its  usual  height  must  not,  under 
such  circumstances,  be  regarded  as  a  sign  of  enlargement. 
Greater  difiiculty,  however,  in  diagnosis  may  result  from  tu- 
mours in  the  omentum  or  of  the  right  kidney,  being  in  the  im- 
mediate proximity  of  the  liver,  and  appearing  to  be  tumours  of 
the  liver  itself.  The  difiiculty  will  be  increased  if  such  tumours 
compress  the  common  bile-duct,  so  as  to  occasion  jaundice. 
The  diagnosis  of  an  omental  tumour  under  such  circumstances 
must  mainly  depend  on  the  want  of  all  uniformity  in  the  ap- 

'  Clinical  Memoirs  on  Abdominal  Tumours.     Syd.  See.  ed.  p.  257. 
*  Stokes.     Op.  cit.  p.  617. 


14  ENLARGEMENTS    OF    THE    LIVER.  lect.  i. 

parent  hepatic  enlargement,  the  dimensions  of  the  liver  in  every 
other  direction  being  normal.  Moreover,  in  both  tumours  of 
the  kidney  and  of  the  omentum,  when  the  patient  lies  on  his 
back,  the  finger  can  usually  be  inserted  between  the  ribs  and  the 
upper  part  of  the  tumour ;  there  is  often  a  clear  space  on  per- 
cussion between  the  tumour  and  the  liver ;  and  the  lower  margin 
of  the  tumour  does  not  ascend  and  descend  with  expiration  and 
inspiration ;  while  the  diagnosis  will  often  be  assisted  by  the 
direction  in  which  the  tumour  has  grown,  and  by  the  history  of 
the  case.  There  are,  however,  certain  difiiculties  in  the  dia- 
gnosis which  must  be  kept  in  view.  (Case  VIII.)  An  omental 
tumour  adherent  to  the  liver  may  descend  with  it  on  inspira- 
tion. The  kidneys,  and  particularly  the  right  one,  may  be  felt 
when  healthy  to  descend  slightly  on  deep  inspiration,  but  this 
rarely  occurs  in  the  case  of  a  renal  tumour  large  enough  to  be 
mistaken  for  an  enlarged  liver.  On  the  other  hand,  an  enlarged 
liver  may  be  prevented  by  peritoneal  adhesions  from  moving 
with  expiration  and  inspiration.  Again,  the  liver  may  be 
pressed  to  the  right  by  a  distended  colon  or  stomach,  so  as 
to  simulate  an  enlarged  kidney,  or  the  transverse  colon  may 
pass  in  front  of  an  enlarged  liver,  so  as  apparently  to  divide  it 
into  two  distinct  solid  tumours. 

Accumulations  of  faeces  in  the  transverse  colon  also  consti- 
tute a  condition  which  it  is  often  most  diflBcult  to  distinguish 
from  enlargement  of  the  liver.  Such  cases  are  constantly 
occurring  in  practice,  and  it  is  well  to  bear  in  mind  that,  if 
you  are  to  rely  on  the  patient's  statements,  these  accumulations 
are  far  from  being  necessarily  associated  with  constipation. 
The  resemblance  to  hepatic  disease  in  these  cases  may  be 
further  increased  by  the  hardened  scybala  imparting  to  the 
tumour  a  nodulated  character  like  that  of  cancer,  and  by  the 
development  of  such  symjDtoms  as  jaundice,  vomiting,  and 
hiccup.  The  diagnosis  of  these  cases  from  true  enlargement 
of  the  liver  must  rest  mainly  on — 

1.  The  occurrence  of  simsmodic  pains  like  those  resulting 
from  obstructed  bowels,  &c. 

2.  The  disappearance  of  the  tumour,  and  the  amelioration 
of  the  symptoms  under  such  treatment  as  poultices  and  fomen- 
tations, purgatives,  enemata,  and  belladonna. 

Lastly  : — 

VIII.  Abnormal  conditions  of  the  abdominal  parietes  may 
simulate  enlargements  of  the  liver. 


LECT.  I,  SPUEIOUS    ENLARGEMENTS.  1$ 

Firm  contraction  of  the  bellies  of  tlie  recti  muscles,  owing 
either  to  inflammation  of  the  subjacent  peritoneum  or  viscera, 
or,  in  cases  of  increased  muscular  irritability,  to  the  mere 
application  of  the  hand,  is  apt  to  be  mistaken  for  hepatic  en- 
largement, or  tumour ;  and  the  difficulty  is  increased  by  the 
circumstance  that  the  upper  division  of  the  rectus  is  sometimes 
larger  on  one  (usually  the  right)  side  than  on  the  other.  It 
is  distinguished  by  : — 

1.  The  situation,  size,  and  form  of  the  apparent  tumour 
corresponding  to  one  of  the  divisions  of  the  rectus  muscle. 

2.  The  sound  on  percussion  being  usually  more  clear  and 
tympanitic  than  it  would  be  over  a  solid  tumour. 

3.  When  the  patient  is  made  to  sit  up  in  bed,  the  swelling 
contracts  and  becomes  thicker. 

4.  When  the  patient  is  placed  on  his  back,  with  his 
shoulders  raised  and  his  thighs  flexed  on  the  abdomen,  and 
his  attention  is  engaged  by  conversation  or  by  making  him 
count,  the  tumour  may  disappear ;  and  it  will  certainly  do  so 
if  he  be  placed  under  the  influence  of  chloroform. 

The  diagnosis  may  also  be  considerably  embarrassed  by  an 
inflammatory  swelling  in  the  abdominal  parietes  over  the 
liver.  This  has  often  been  mistaken  for  an  abscess  of  the  liver 
itself.  Several  remarkable  instances  of  this  sort  have  come 
under  my  notice,  in  which,  for  some  days,  the  diagnosis  has 
been  very  doubtful.  '  The  following  characters  usually  suffice 
to  distinguish  this  condition  from  hepatic  disease  :- — 

1.  The  margin  of  inflammation  and  of  dulness  on  percussion 
is  ill-defined,  and  does  not  correspond  to  the  boundary  of  an 
enlarged  liver. 

2.  There  is  a  greater  amount  of  hardness  and  tightness  of 
the  superimposed  integuments. 

3.  The  constitutional  symptoms  are  comparatively  slight ; 
rigors  and  profuse  sweatings  rarely  occur,  and  there  are  no 
indications  of  severe  hepatic  derangement. 

4.  The  lower  margin  of  the  swelling  does  not  ascend  and 
descend  with  respiration,  but  this  character  may  hold  good  in 
adherent  hepatic  abscess. 

Keeping  in  view  these  sources  of  fallacy,  we  proceed  to 
consider  the  various  causes  of  true  enlargement  of  the  liver. 

The  following  cases  illustrate  some  of  the  ways  in  which 
enlargement  of  the  liver  may  be  simulated.     Cases   I.  and  II. 


1 6  ENLARGEMENTS   OF   THE   LIVER.  lect.  i. 

are  examples  of  a  circumscribed  empyema  pointing  below  the 
ribs  and  causing  great  depression  of  the  liver. 

Case  I. — Circumscribed  Empyema  of  right  side,  displacing  liver  down- 
boards,  and  simulating  hepatic  disease.  Paracentesis  belotv  ribs  and 
introduction  of  a  drainage-tube.     Recovery. 

Charlotte   T ,  aged   8,  admitted    into   St.    Thomas's  Hospital 

May  22,  1872.  Always  delicate,  but  present  illness  had  commeuced 
six  weeks  before  with  rigors  followed  by  pyrexia,  loss  of  appetite, 
and  emaciation  ;  she  had  lain  continnally  on  right  side.  Her  con- 
dition on  June  1  was  as  follow^s :  Liver  appears  enormously  enlarged, 
npper  part  of  abdomen  distinctly  bulging,  especially  on  right  side,  and 
lower  margin  of  liver  descending  to  umbilicus.  Abdominal  veins  un- 
usually distinct  and  apparently  much  enlarged ;  no  ascites  and  abdo- 
minal walls  move  freely  in  respiration.  On  right  side  of  chest,  dul- 
ness  on  percussion  from  liver  to  upper  edge  of  nipple  ;  above  this  clear 
percussion-sound  and  vesicular  breathing,  but  below  the  nipple  dis- 
tinct circumscribed  bulging  of  ribs  and  of  intei"costal  spaces,  with 
fluctuation  between  the  ribs  and  also  below  them  in  right  hypochon- 
drium.  Posteriorly,  the  dulness,  absence  of  breathing,  and  bulging 
of  intercostal  spaces  extend  over  lower  two-thirds  of  right  chest. 
Upper  margin  of  dulness  distinctly  arched  and  has  not  ascended  since 
patient's  admission,  but  lateral  bulging  has  increased  much.  Respira- 
tions 50  ;  much  pain  and  distress  on  slightest  movement.  Pulse  150  ; 
apex  of  heart  felt  between  5th  and  6th  ribs,  half-an-inch  outside  left 
nipple.  Temperature  since  admission  has  ranged  from  99  6°  to 
102"8° ;  no  rigors ;  for  last  three  nights  has  perspired  profusely. 
After  an  exploratory  puncture,  a  large  trocar  was  introduced  into 
the  swelling  beloio  the  right  ribs  in  front,  and  53  ounces  of  pus  drawn 
off;  the  first  that  came  was  thin,  but  the  last  thick  and  opaque.  Tlie 
opening  was  enlarged  and  a  drainage-tube  fastened  in.  The  breath- 
ing was  at  once  relieved,  and  it  was  observed  during  the  operation 
that  the  lower  margin  of  liver  ascended  at  least  two  inches,  but  that  no 
change  took  place  in  level  of  upper  margin  of  dtdness  in  right  chest. 

Next  day  child  was  much  better.  Pulse  114  ;  respirations  30 ;  tem- 
perature 97-8°. 

June  22. — Continued  to  improve  for  a  week  after  operation,  but 
for  last  13  days  temperature  has  varied  from  98'4°  to  103°,  and  pulse 
from  120  to  150,  and  for  several  days  pus  discharged  by  tube  has 
been  fetid,  although  cavity  has  been  washed  out  daily  with  Condy's 
fluid.  Sleeps  Avell ;  takes  food  -well ;  and  has  had  no  rigors.  Under 
chloroform  a  counter-opening  was  made  at  back  between  ninth  and 
tenth  ribs,  and  a  perforated  elastic  drainage  tube  was  passed  through 
the  two  openings.  About  six  ounces  of  very  fetid  pus  came  away 
during  operation,  and  nearly  a  pint,  also  fetid,  within  next  two  days. 


LECT.  I,  CASES    OF    SIMULATED    ENLARGEMENT.  1/ 

The    cavity  was  now  washed  out  daily  with  a  solution  of  carbolic 
acid  (t-Jht)- 

The  qaantity  of  discharge  gradually  diminished,  until  by  the 
middle  of  August  there  was  only  a  slight  oozing  of  yellowish  serum. 
The  tube  might  have  been  now  removed,  but  daring  my  absence 
from  town  it  was  retained  until  Sept.  28 ;  within  a  few  days  of  its 
removal  both  openings  healed.  From  a  few  days  after  counter-open- 
ing was  made,  patient  steadily  improved  in  general  health,  and  when 
she  was  discharged  on  Nov.  1,  she  was  plump  and  hearty,  and  for 
several  weeks  had  been  running  about  the  ward.  There  was  no  dif- 
ference on  measurement,  and  scarcely  any  on  inspection,  between  the 
two  sides  of  the  chest ;  if  any,  it  was  a  slight  excavation  below  right 
nipple.  Hepatic  dulness  commenced  at  upper  margin  of  sixth  rib,  1-g- 
inch  below  nipple,  and  extended  3  inches  downwards,  but  not  below 
edge  of  ribs.  Clear  percussion  on  right  side  posteriorly,  with  vesicular 
breathing  do>vn  to  normal  level. 

Case  II. — Circumscribed  Empyema,  pointing  at  Epigastrium  and 
depressing  Liver.     Paracentesis  in  Epigastrium.     Recovery. 

On  Dec.  23,  1875,  I  was  requested  to  see  a  butcher,  aged  40,  who 
was  supposed  to  have  some  serious  disease  of  liver — hydatid  or  cancer. 
On  careful  enquiiy,  following  history  was  elicited.  For  six  or  eight 
months  he  had  complained  of  flatulent  distension  of  stomach,  but  ex- 
cepting this  he  had  been  in  good  health  and  attending  to  business, 
until  beginning  of  November,  when,  after  a  chill,  he  was  seized  with 
severe  pain  across  loin's  and  general  illness.  After  three  days  he  sent 
for  a  doctor,  who  noted  dulness  over  back  of  right  lung  and  dry  cough. 
Seven  or  eight  days  after  this,  during  doctor's  visit,  he  suddenly 
coughed  up  for  first  time  a  quantity  of  yellow  matter ;  the  expectora- 
tion continued  for  about  a  week,  when  it  suddenly  ceased.  About 
Dec.  14  a  swelling  appeared  at  epigastrium  with  considerable  pain, 
and  about  same  time  dulness  at  back  of  right  lung  receded. 

At  time  of  my  visit,  lower  margin  of  liver  was  about  one  inch 
below  umbilicus,  its  position  not  influenced  by  inspiration  ;  in  epigas- 
trium was  a  circumscribed  fluctuating  bulging  five  inches  in  diameter, 
tender,  but  less  so  than  it  had  been.  Lower  right  costal  cartilages 
everted.  At  base  of  right  lung  feeble  breathing  and  some  crackling 
sounds.  Resp.  24.  Pulse  100.  Temp.  100°;  no  rigors  or  profuse 
perspirations.  Appetite  bad  ;  sleep  disturbed.  An  exploratory  punc- 
ture was  made  in  epigastrium,  and  a  tablespoonful  of  thick  fetid  pus 
escaped. 

Next  day  nearly  two  pints  of  pus  were  drawn  ofi"  through  a  larger 
opening,  a  piece  of  elastic  tube  was  tied  in,  and  through  this  the 
cavity  was  washed  out,  first  with  three  fluid  ounces  of  a  solution  of 
chloride  of  zinc  (30  grains  to  ounce),  and  subsequently  with  a  weak 

0 


1 8  ENLARGEMENTS    OF   THE    LIVER.  lect.  i. 

solution  of  cai'bolic  acid.      Tube  at    first  passed   straight  back  into 
cavity  to  extent  of  8  or  10  inches. 

After  tapping,  patient  never  had  a  bad  symptom  ;  he  ate  and  slept 
well,  and  on  Jan.  7  discharge  from  opening  was  reduced  to  two 
di'achms  daily.  On  Feb.  6  he  came  down  stairs,  ate  and  slept  well ; 
on  Feb.  17  there  was  only  a  little  glairy  discharge  from  wound,  and 
tube  was  removed. 

In  Case  III.  the  liver  appeared  to  be  enlarged  in  con- 
sequence of  displacement  by  a  psoas  abscess. 

Case  III. — Caries  of  Spine.     Psoas  Abscess.     Displaced  Liver 
simvJating  Enlargement.     Sypliilitic  Peri-hepatitis. 

Catherine  F ,  27,  admitted  into  St.  Thomas's  Hospital,  May  28, 

1875,  supposed  to  be  suffering  from  enlargement  of  liver.  Father, 
mother,  and  probably  one  brother  had  died  of  phthisis.  Married  3 
years ;  no  children  and  no  miscarriages.  Six  months  before  admis- 
sion had  ulcerated  sore  throat  and  swelling  of  glands  in  neck  which 
were  lanced.  About  same  time  began  to  have  a  dull  pain  in  back. 
This  would  often  come  on  when  going  about  house,  and  would  compel 
her  to  sit  down  for  a  few  minutes.  It  continued  until  six  weeks  be- 
fore admission,  when  she  was  seized  with  severe  pain  in  lower  right 
chest,  increased  by  inspiration,  and  accompanied  by  dyspnoea,  cough, 
expectoration  of  phlegm  mixed  with  blood,  vomiting,  constipation,  and 
for  first  week  rigors  every  night.  After  three  weeks  cough  ceased, 
but  pain  persisted.  Ten  days  before  admission,  first  noticed  swelling 
in  right  hypochondrium,  which  advanced  towards  umbilicus  with  in- 
creased pain. 

On  admission,  pale,  thin,  and  anxious.  Much  pain  in  right  side 
of  abdomen,  and  swelling  distinctly  felt  below  right  ribs  extending 
down  to  umbilicus,  Avhere  it  turns  rather  abruptly  upwards  to  left  side 
of  ensiform  cartilage.  To  right,  it  extends  as  far  as  free  end  of 
twelfth  rib.  Whole  of  this  space  tense  and  tender.  Upper  margin  of 
hepatic  dulness  extends  to  upper  border  of  fourth  rib,  making  entire 
dulness  in  r.  m.  1.  8^  in.  Distinct  bulging  of  right  lower  ribs,  and 
obliteration  of  intercostal  spaces  in  front.  Posteriorly,  what  appears 
to  bo  hepatic  dulness  extenils  fully  two  inches  above  normal  level,  but 
above  this  vesicular  breathing  without  rale.  In  right  lumbar  region 
below  last  rib,  a  distinct  elastic  bulging  apparently  containing  fluid. 
Marked  tenderness  on  pressure  over  three  or  four  of  lower  dorsal 
spines.  Tongue  dry,  red,  and  glazed ;  no  appetite ;  much  thirst ; 
occasional  vomiting  ;  bowels  confined.  Temp,  varies  from  90°  to  103°; 
night-sweats :  rigor  last  night.  Pulse  132.  Glands  in  right  groin 
large  and  tender.     Albumen  (^)  in  urine. 

Treatment  consisted  in  quinine,  mineral  acids,  opium,  and  ape- 
rients.    Continued   to   get  worse.     June  0,  abscess  pointing   below. 


LECT.  I.  CASES    OF    SIMULATED    ENLARGEMENT.  I9 

Poupart's  ligament  on  right  side ;  pain  in  micturition ;  temp,  varies 
from  99-5°  to  104-6°.  June  22.  No  albuminuria.  On  June  29,  8^ 
oz.  of  thick  yellow  pus  drawn  off  by  aspirator  from  swelling  in  right 
lumbar  region,  and  swelling  in  groin  at  once  collapsed.  The  eflPect  of 
this  was  to  relieve  pain  and  lower  temperature  ;  but  after  a  few  days 
swelling  in  groin  returned,  with  much  pain  ;  and  on  July  5  severe  pain 
and  tenderness  in  splenic  region  and  general  distension  of  abdomen. 
On  July  6  one  pint  of  pus  let  out  by  incision  from  swelling  in  groin, 
and  there  was  abundant  subsequent  discharge.  Pain  and  fever 
greatly  abated  ;  but  patient  became  rapidly  weaker ;  vomiting  be- 
came urgent,  aphthae  formed  in  mouth,  and  on  July  22  she  died. 

Autopsy. — Liver  occupied  whole  of  upper  part  of  abdomen  in  front, 
but  weighed  only  58  oz.  and  was  not  at  all  enlarged,  being  displaced 
forwards  by  a  large  abscess  in  connection  with  caries  of  right  trans- 
verse processes  and  adjoining  parts  of  bodies  of  10th,  11th,  and  12th 
dorsal  vertebree,  and  of  proximal  ends  of  last  three  right  ribs.  Ab- 
scess communicated  below  with  opening  in  right  groin,  and  above  by 
a  ragged  ulcerated  opening  with  a  circumscribed  cavity  containing  six 
ounces  of  pus  in  left  pleura.  Surface  of  liver  marked  by  several  deep 
(syphilitic)  scars.     Spleen  8  oz.     Kidneys  apparently  healthy. 

In  Case  IV.  a  great  enlargement  of  the  liver  was  simulated 
by  an  aortic  aneurism,  which  had  ruptured  and  given  rise  to 
a  large  collection  of  blood  pressing  the  liver  downwards  and 
forwards.  The  case  was  remarkable  for  several  other  reasons. 
The  history  and  autopsy  left  little  doubt  as  to  what  was  the 
sequence  of  events  :' 

1.  An  aneurism  formed  at  the  lower  part  of  the  thoracic 
and  upper  part  of  the  abdominal  aorta,  without  causing  any 
symptoms. 

2.  On  January  1  this  aneurism  ruptured  and  caused  syn- 
cope, and  blood  burrowing  from,  the  mediastinum  behind  right 
pleura  excited  pleuropneumonia. 

3.  The  pressure  of  the  aneurism  eroded  the  bodies  of  the 
vertebree,  and  accounted  for  the  persistent  dorsal  pain. 

4.  In  August  the  aneurismburst  in  a  downward  direction, and 
the  blood  pressing  forward  the  liver  and  the  peritoneum  appeared 
at  the  epigastrium,  excited  chronic  peritonitis,  and  interfered 
with  the  portal  circulation.  But  during  life  the  diagnosis 
was  rendered  difficult  by  the  absence  of  the  ordinary  physical 
signs  of  aneurism.  An  empyema,  an  abscess  of  the  liver,  or  an 
abscess  in  connection  w'ith  carious  vertebrae,  was  excluded  b}^ 
the  absence  of  pyrexia ;  and  hydatid  cyst  was  negatived  by  the 
rapidity  of  growth,  coupled  with  the  absence  of  pyrexia,  which 

c  2 


20  ENLARGEMENTS    OF    THE    LIVER.  lfxt.  t. 

■would  have  resulted  from  a  hydatid  that  had  taken  on  inflamma- 
tion. But  peritonitis,  extending  over  many  weeks  and  leading 
to  great  accumulation  of  fluid  in  the  peritoneum,  is  in  most 
instances  the  result  of  cancer,  and  this  was  likewise  indicated 
by  the  constant  vomiting,  the  attacks  of  severe  abdominal  pain, 
the  presence  of  a  large  tumour  in  the  abdomen,  and  the 
emaciation ;  while  the  separate  collection  of  fluid  in  the  epi- 
gastrium might  have  been  explained  by  a  portion  of  the  peri- 
toneal fluid  being  encysted  above  the  liver.  The  only  sym- 
ptoms pointing  to  aneurism  were  the  syncope  which  preceded 
the  attack  of  pleuropneumonia  and  the  persistent  dorsal  pain. 

Case  IV. — Diffuse  Aneiirism  of  ThoracAc  and  Abdominal  Aorta,  termi. 
nating  in  Chronic  Peritonitis,  with  coinous  liquid  Effusion. 

James  D ,  aged  42,  coachman    to   a   surgeon,  admitted   into 

Middlesex  Hosp.,  Sept.  13,  1869,  suffering  from  peritonitis.  His 
father  and  mother  had  both  been  strong  and  healthy,  and  had  both 
lived  to  over  seventy :  they  had  left  a  family  of  twelve  children,  of 
whom  all  were  alive,  and  only  one  sister  was  delicate.  Excepting  the 
usual  infantile  diseases,  patient  had  always  enjoyed  excellent  health. 
He  had  formerly  been  engaged  in  the  ice  trade,  and  had  then  been 
accustomed  to  drink  much  beer  and  spirits,  but  for  two  years  he  had 
been  a  gentleman's  coachman  and  had  lived  more  temperately.  On 
Jan.  1,  1869,  while  cleaning  brougham,  he  suddenly  felt  very  ill ;  he 
was  able  to  lie  down  upon  some  straw,  but  he  then  became  quite  un- 
conscious, and  according  to  his  master's  (a  surgeon)  account  he  re- 
mained in  a  state  of  profound  syncope  for  half  an  hour.  Immediately 
after  this  he  had  an  attack  of  right  pleuropneumonia,  by  which  he 
was  laid  up  nine  weeks ;  but  in  beginning  of  March  he  was  able  to 
resume  work,  and  for  nearly  five  months  he  drove  out  every  day. 
Still  all  this  time  he  complained  of  a  severe  and  constant  aching  pain 
in  back  and  right  shoulder ;  his  appetite  was  good,  though  not  so 
good  as  before  ;  he  had  no  pain  in  abdomen,  and  no  sickness. 

At  beginning  of  August,  without  any  strain  or  unusual  exertion, 
or  in  fact  any  obvious  exciting  cause,  patient  was  suddenly  taken  with 
urgent  vomiting  and  severe  pain  and  distension  of  abdomen,  with  con- 
stipation ;  these  symptoms  lasted  about  a  fortnight,  when  they  gra- 
dually passed  off  and  he  recovered  his  appetite.  On  Sept.  4  sickness 
i-eturned  and  was  attended  by  pain  in  stomach,  but  less  severe  than 
on  former  occasion.  Tlie  patient,  however,  had  severe  pain  in  right 
shoulder  and  great  thirst,  and  abdomen  began  to  enlarge.  After  two 
or  three  days  he  felt  better  again,  and  for  two  days  be  was  able  to  go 
out  for  a  little,  but  on  10th  he  became  worse,  and  since  then  he  had 
suffered  acute  pain,  and  had  vomited  everything  he  swallowed.     For 


LECT.  I.  CASES    OP    SIMULATED    ENLARGEMENT.  21 

nine  days  iiis  bowels  had  been  relaxed,  and  shortly  before  admission 
he  had  passed  a  considerable  quantity  of  semi-coagulated  blood  from 
bowel,  which  his  wife  compared  to  clots  passed  after  childbirth.  Ho 
had  never  suffered  from  piles. 

The  patient's  '  state  on  admission  '  was  noted  as  follows :  '  Very 
emaciated.  Still  suffers  much  from  constant  aching  pain  in  back,  but 
at  present  chief  complaints  are  of  pain  and  swelling  of  abdomen,  and 
of  inability  to  retain  anything  on  stomach.  Abdomen  is  considerably 
distended,  tense,  and  tender  ;  it  measures  at  umbilicus  32  inches,  this 
enlargement  beiiig  due  partly  to  fluid  in  peritoneum,  but  mainly  to  a 
tumour  occupying  centre  and  upper  part  of  abdomen,  and  apparently 
connected  with  liver.  Hepatic  dulness  in  right  mammary  line  6^ 
inches  ;  in  sternal  line,  it  extends  to  3  inches  below  umbilicus,  and 
measures  10  inches.  The  lower  4  inches  of  this  mass  feel  smooth 
and  firm ;  its  edge  is  well  defined  and  does  not  ascend  and  descend 
with  respiration  ;  but  above  this,  in  epigastrium,  there  is  distinct 
fluctuation  with  a  circumscribed  bulging  over  a  space  6  or  6  inches  in 
diameter.  The  fluid  in  this  situation  is  evidently  encysted  and  dis- 
tinct from  that  in  peritoneum ;  the  thrill  produced  by  tapping  other 
parts  of  the  abdomen  is  not  propagated  to  it,  and  the  bulging  at  epi- 
gastrium does  not  vary  with  position  of  patient.  The  abdominal  walls 
scarcely  move  in  respiration.  Patient  lies  for  the  most  part  on  right 
side,  and  says  pain  is  always  increased  when  he  turns  on  left ;  he 
is  also  liable  to  paroxysms  of  severe  abdominal  pain  irrespectively  of 
position.  1^0  enlargement  of  abdominal  veins ;  no  obvious  enlarge- 
ment of  spleen  ;  no  jaundice  ;  tongue  moist  and  white  ;  says  he  vomits 
almost  immediately  after  eating ;  bowels  open  three  times  to-day. 
Pulse  108,  regular  and  feeble  ;  apex  of  heart  elevated,  beating  in 
nipple  line  ;  no  abnormal  pulsation  or  bellows-murmur  anywhere  over 
chest  or  abdomen.  Occasional  cough ;  respirations  36  ;  perceptible 
respiratory  movement  almost  entirely  confined  to  left  side  of  chest ; 
over  whole  of  right  lung  there  is  marked  dulness  on  percussion,  with 
very  feeble  tubular  breathing  ;  in  front  vocal  resonance,  and  still 
more  vocal  thrill,  are  exaggerated  ;  posteriorly  they  are  absent.  Skin 
covered  with  a  clammy  sweat ;  temperature  97'8°  ;  slight  oedema  of 
feet  and  ankles.  Urine  contains  ^  (in  volume)  of  albumen  and  much 
lithates.' 

Patient  was  ordered  ice,  lime-water  and  milk,  with  brandy,  a  grain 
of  opium  twice  a  day,  and  poultices  to  abdomen.  Subcutaneous  in- 
jections of  morphia  were  afterwards  substituted  for  the  opium  pills. 

Under  this  treatment  diarrhoea  was  at  once  checked,  and  by  Sept. 
20  vomiting  had  also  ceased,  and  patient's  general  appearance  at  first 
improved.  The  abdomen,  however,  slowly  but  steadily  increased  in 
size,  and  on  Sept.  29  parietes  were  tense  and  glistening,  and  girth  at 
umbilicus  33|  inches.  On  Oct.  2  skin  and  conjunctivae  were  slightly 
yellow,  and  there  was  bile-pigment  in  urine.     On   Oct.  18  girth  at 


22  ENLARGEMENTS    OP    THE    LIVER.  lect.  i. 

nmbilicns  had  increased  to  35  inches,  and  patient  complained  mncli  of 
paroxysmal  pain  and  tightness  in  abdomen,  and  of  increasing  weak- 
ness. Pulse  was  usually  about  96,  and  temperature  about  97'5°.  On 
Oct.  22  there  Avas  a  great  increase  of  abdominal  pain,  attended  towards 
evening  by  vomiting.  He  gi*adually  sank,  and  died  on  morning  of 
23rd. 

On  j7os/-7»or^e7/i  examination  several  quarts  of  turbid  alkaline 
serum,  having  a  specific  gravity  of  1020,  and  containing  flakes  of 
lymph  and  pus-corpuscles,  in  peritoneal  cavity.  Intestines  and  other 
iibdominal  viscera,  and  peritoneal  lining  of  abdominal  wall,  coated  with 
a  thin  layer  of  recent  lymph  easily  peeled  ofi".  Nowhere  any  sign  of 
tubercle  or  cancer.  Liver  extended  downwards  beyond  umbilicus  ; 
its  tissue  was  firm,  but  did  not  seem  abnormal.  Between  liver  and 
diaphragm  was  an  enormous  cyst,  quite  distinct  from  jDeritoneum, 
and  containing  fluid  red  blood.  On  opening  chest,  right  lung  was 
found  to  be  everywhere  firmly  adherent,  collapsed,  dense,  and  carni- 
fied.  Posteriorly,  beneath  thickened  pleura,  and  extending  as  high  as 
third  rib,  and  outwards  to  angles  of  ribs,  was  another  collection  of 
fluid  blood ;  and  on  further  examination  this  blood,  and  that  above 
liver,  were  found  to  be  contained  in  a  common  sac,  formed  by  a  large 
nneurism  of  lower  jmrt  of  thoracic  aorta  originating  immediately  above 
diaphragm,  and  terminating  below  at  origin  of  superior  mesenteric 
artery.  This  aneui'ism  consisted  of  a  large  rounded  sac  formed  by  a 
dilatation  of  entire  aorta  over  two  or  three  inches  of  its  course.  The 
arterial  trunk  entered  this  sac  abruptly  above,  and  passed  ofi"  from  it 
as  abruptly  below.  The  coeliac  axis  was  given  ofi'  from  near  lower  end 
of  sac.  On  right  side  the  sac  had  given  way,  and  blood  was  infiltrated 
between  its  coats  for  a  short  distance,  but  entire  coats  had  also  rup- 
tured behind  peritoneum,  and  blood  escaping  had  dissected  its  way 
in  diff'erent  directions.  The  main  portion  was  that  seen  at  epigastrium 
above  the  liver,  but  it  had  also  burrowed  upwards  behind  right  pleura. 
]t  contained  several  pints  of  blood,  and  its  walls  were  formed  partly 
liy  expanded  coats  of  the  vessel,  lined  with  laminated  fibrin  at  some 
l)laces  nearly  an  inch  thick,  and  partly  by  diaphragm,  liver,  vertebra3, 
libs,  and  pleura.  The  bodies  of  lower  dorsal  vertebrae  were  eroded 
iind  rough,  and  right  ribs,  at  their  origin,  were  also  bared.  The  en- 
tire  liver  was  displaced  forwards,  so  that  its  upper  surface  was  op- 
posed to  anterior  abdominal  wall ;  in  this  way  organ  appeared  to  be 
enlarged,  but  its  weight  was  only  54  ounces.  Heart  not  enlarged,  and 
valvos  healthy  ;  extensive  atheroma  of  aorta.  Loft  lung  voluminous 
and  healthy.  Kight  kidney  compressed  and  altered  in  shape  by 
aneurism,  and  its  cortex  at  point  of  contact  opaque  and  white.  Mu- 
cous membrane  of  stomach  was  intensely  injected,  and  studded  with 
hasraorrliagic  erosions. 

In   Case   V.  it  liad  been  supposed  that   the   patient  was 


I.RCT.  I.  CASES    or    SIMULATED    ENLARGEMENT.  23 

suffering-  from  a  tumour  of  the  liver,  but  more  probably  this 
was  simulated  by  a  collection  of  fluid  between  the  liver  and 
dia]ohragm.  If  the  tumour  originated  in  the  liver,  it  could 
only  have  been  an  abscess  or  a  hydatid.  The  former  was  ex- 
cluded by  the  absence  of  constitutional  symptoms  and  the 
transparency  of  the  tumour,  to  say  nothing  of  the  rarity  of  a 
large  solitary  abscess  in  a  boy  who  had  never  left  this  country  ; 
while  hydatid  was  rendered  improbable  by  the  rapid  growth, 
the  absence  of  any  trace  of  echinococci  in  the  contents,  and 
the  fact  that  a  cup-shaped  indurated  base  could  be  felt  after 
the  sac  was  emptied.  The  anatomical  relations  negatived  a 
renal  cyst,  and  a  chronic  abscess  of  the  abdominal  parietes  was 
excluded  by  the  absence  of  pyrexia,  by  the  effect  upon  the  tumour 
of  coughing,  inspiration,  pressure,  and  position,  by  the  e version 
of  the  ribs  and  the  displacement  of  the  heart,  and  by  the  direc- 
tion which  the  probe  took  after  the  bursting  of  the  sac.  The 
diagnosis  which  seemed  most  in  accordance  with  all  the  facts 
of  the  case  was  that  there  was  a  circumscribed  inflammatory 
effusion  between  the  liver  and  the  diaphragm ;  and  it  seemed 
possible  that  the  '  ascites  '  which  followed  the  varicella  might 
have  been  tubercular,  and  that  the  injury  to  the  back  rekindled 
a  fresh  but  localised  inflammatory  process.  In  reference  to 
this  case,  the  following  remarks  of  Wilks  and  Moxon  are  of 
interest: — 'We  have  seen  several  cases  of  large  abscesses 
between  the  liver  and  diaphragm,  or  between  the  liver  and 
stomach ;  the  liver-tissue  being  only  compressed  by,  and  not 
involved  in,  the  abscesses,  which  lay  quite  outside  of  it.  Some 
of  these  were  traced  to  injuries,  but  for  others  no  cause  could 
be  assigned.'  * 

Case  Y. — Circumscribed  Peritoneal  Effusion  between  Liver  and 
Diaphragm,  depressing  Liver. 

John  J ,  aged  10,  was  admitted  into  Middlesex  Hosp.  under 

my  care,  June  29,  1869.  His  father  and  mother  were  in  good  health  ; 
a  brother  and  a  sister  had  died  of  scarlet  fever,  and  he  had  two 
brothers  and  two  sisbers  alive  and  well.  In  infancy  he  had  passed 
through  measles  and  scarlet  fever,  and  early  in  1867  he  had  what  was 
supposed  to  be  an  attack  of  varicella  followed  by  temporary  ascites. 
Since  this  last  attack  he  had  been  rather  weakly.  About  May  1868, 
he  was  struck  on  the  back  by  a  truck ;  he  did  not  seem  to  experience 
any  uneasmess  from  this  at  the  time,  but  in   September  he  becarae 

'  Lect.  on  Path,  Anat.,  2nd  ed.,  p.  446, 


24 


ENLARGEMENTS    OF    THE    LIVER. 


■weaker,  and  began  to  complain  of  pain  in  the  region  of  the  liver,  in- 
creased hj  taking  a.  deep  breath,  and  Dr.  Schulhof,  who  then  saw  him, 
found  a  slight  bulging  of  the  right  lower  ribs,  and  noticed  that  the 
boj  always  leant  to  the  right  side.  At  end  of  December  he  contracted 
a  second  mild  attack  of  scarlatina,  and  about  middle  of  February, 
when  Dr.  Schulhof  saw  him  again,  there  Avas  a  fluctuating  painless 
swelling  about  the  size  of  a  hen's  egg  below  right  ribs,  which  could  be 
forced  up  under  the  ribs  when  the  boy  lay  on  his  back.  From  this 
time  the  tumour  gradually  increased  in  size  without  causing  any  pain. 
On  admission,  there  was  found  to  be  a  globular  tumour  in  right 
liypochondrium,  commencing  immediately  below,  and  not  overlapping, 
the  right  ribs,  and  extending  to  about  3  inches  below  level  of  um- 
bilicus (see  fig.  9).     It  measured  six  inches  over  its  convexity  ver- 


Fig.  9.     Shows  tumour  in  right  hypochondrium  of  Case  V. 


tically,  G^  inches  transversely,  and  the  circumference  at  its  base  was 
14  inches.  The  cartilages  of  lower  right  ribs  were  slightly  everted, 
and  girth  here  was  ^  inch  more  than  on  left  side.  The  tumour  was 
painless  and  distinctly  fluctuating  thi-oughout,  and  there  was  no  in- 
duration at  its  base.  It  exhibited  a  slightly  bluish  translucent  ap- 
pearance, and  the  light  of  the  sun  or  of  a  candle  was  distinctly  trans- 
mitted through  it.  When  patient  coughed,  an  impulse  was  conveyed 
to  tumour,  and  when  he  lay  on  his  back  and  plaster  of  Paris  was 
applied  over  tumour,  with  the  object  of  taking  a  cast,  a  portion  of 
tumour  seemed  to  disappear  beneath  ribs  ;  the  tumour  was  always 
largest  when  he  sal^  up.  There  was  clear  vesicular  breathing  at  base 
of  right  lung,  which  descended  to  normal  level  both  anteriorly  and 


LECT.  I.  CASES    OP    SIMULATED    ENLARGEMENT.  25 

posteriorly.  The  lower  edge  of  liver  could  not  be  felt  tlirough  tumour, 
which  descended  slightly  on  patient's  taking  a  deep  inspiration. 
There  was  tympanitic  percussion  noted  between  tumour  and  right 
kidney  ;  no  tenderness  or  curvature  of  spine ;  apex  of  heart  beat  be- 
tween 4th  and  5th  ribs,  immediately  below  lelt  nipple.  The  boy's 
general  health  was  good  ;  he  was  rather  thin  and.  pale,  but  had  no 
pyrexia,  and  ate  and  drank  well ;  he  had  no  sign  of  pulmonary,  car- 
diac, or  renal  disease,  and.  no  jaundice. 

On  April  14  the  tumour  was  punctured  with  a  trocar,  and  15 
fluid  ounces  drawn  off  of  thin  pus,  having  a  specific  gravity  of  1028 
and  separating  on  standing  into  two  layers  of  about  equal  volume,  the 
upper  clear  and  straw-coloured,  the  lower  opaque  and  yellow,  and 
under  microscope  exhibiting  pus-corpuscles  and  compound  granular 
bodies,  but  no  traces  of  echinococci  or  cholesterin.  The  chemical 
examination  of  the  matter  gave  the  following  result : 

Total  solids 9*7    per  cent. 

Organic  „ 8*64         „ 

Ash         „ -86 

Chloride  of  sodium  ....       '6  „ 

The  rest  of  the  ash  consisted  of  sulphate  of  soda  and  phosphate  of 
lime. 

The  operation  was  followed  by  no  constitutional  disturbance,  but 
in  less  than  two  days  it  was  clear  that  the  sac  was  again  filling,  and 
on  April  29  the  tumour  was  almost  as  large  as  before  it  had  been 
emptied.  On  this  day  it  was  tapped  a  second  time  and  15  fluid  ounces 
of  fluid  were  drawn  off,  similar  to  that  on  first  occasion,  bnt  with. 
less  sediment,  and  baying  a  specific  gravity  of  1022.  On  May  7  a 
third  tapping  brought  away  9  ounces  of  fluid  more  viscid  than  the 
former,  and  containing  compound  granular  corpuscles  adhering  in 
flakes,  but  no  distinct  pus-corpuscles,  and  having  a  specific  gravity  of 
1020.  A  fourth  tapping  brought  away  7  ounces  of  fluid  still  more 
viscid,  specific  gravity  1019,  and  becoming  perfectly  solid  on  boiling. 
On  each  occasion  after  the  tumour  was  emptied,  a  cup-shaped  indura- 
tion could  be  felt  all  round  its  base.  After  the  fourth  opening  the 
tumour  increased  again  very  slowly,  and  on  May  24,  while  patient  was 
lying  upon  it,  it  opened  spontaneously  at  a  spot  below  where  it  had 
been  tapped,  but  where  for  some  time  the  integuments  had  been  thin 
and  dark.  This  spontaneous  opening  continued  to  discharge  a  clear 
viscid  fluid  containing  white  flakes  until  the  patient  left  the  hospital 
on  June  29.  A  probe  could  be  passed  through  the  opening  inwards, 
downwards,  and  outwards  beneath  the  abdominal  wall  to  the  extent 
of  an  inch-and-a-half,  but  upwards  beneath  the  ribs  and  above  the 
liver  to  fully  3  inches.  During  the  boy's  residence  in  hospital  he  had 
gained  flesli  and  improved  greatly  in  strength  and  appearance. 

On  Oct.  5  he  presented  himself  as  an  out-patient.  His  general 
health,  was  still  good.     He  brought  with  him  a  large  quantity  of  cal- 


26  ENLAEGEMENTS    OF   THE    LIVER.  iect.  i. 

careons  flakes  (not  effervescing  with  nitric  acid)  which  had  come 
away  from  the  opening  shortly  after  he  had  left  the  hospital.  The 
opening  had  not  yet  closed,  but  a  probe  could  not'  be  passed  in  any 
direction  farther  than  2  or  3  lines.  Shortly  after  this  the  opening 
permanently  closed,  and  one  day  in  1873  the  boy  presented  himself 
at  St.  Thomas's  Hospital  in  good  health  and  haying  experienced  no 
further  trouble  from  the  swelling. 

Case  YI. — Apparent  Enlargement  of  Liver  due  to  Peritoneal  Adhesions. 

Elizabeth  H ,  aged  44,  admitted  into  Middlesex  Hosp.,  July  15, 

18G8,  suffering  from  cardiac  dropsy  and  other  indications  of  disease  of 
mitral  valve.  There  was  moderate  ascites,  and  apparently  great  en- 
largement of  liver,  which  could  be  felt  as  a  solid  tumour  filling  upper 
part  of  abdomen,  and  extending  down  to  an  inch  below  umbilicus, 
hard,  smooth,  and  very  slightly  tender.  Hepatic  dulness  seemed  to 
extend  upwards  to  about  its  normal  level  in  front,  but  the  presence  of 
fluid  in  pleurse  made  determination  of  this  somewhat  doubtful.  A 
hard  tumour  could  also  be  felt  obscurely  beloAv  left  ribs.  The  dropty 
and  dysjDnoea  gradually  increased,  and  on  Aug.  12  patient  died. 

At  autopsy  liver  was  found  to  be  slightly,  if  at  all,  enlarged ;  but 
its  upper  surface  was  bound  by  firm  adhesions  to  diaphragm  and  ab- 
dominal parietes  to  below  umbilicus.  Its  capsule  was  much  thickened 
and  its  structure  was  dense  and  fibrous ;  it  weighed  Gl  oz.  The 
spleen  was  also  large,  weighing  9  oz.,  and  its  capsule  much  thickened. 

In  tlie  next  case  enlargement  of  the  liver  was  simulated  by 
a  phantom  tumour. 

Case  VII. — Fhantom  Tumour  of  Abdomen  simulating  Hydatid 
of  Liver. 

On  Feb.  17,  1869,  Miss  Hester  D ,  aged  11,  a  healthy-looking 

child,  was  brought  for  my  advice  as  to  tapping  what  Avas  believed  to 
be  a  hydatid  of  the  liver.  Two  years  before,  on  recovering  from  a  low 
fever,  a  tumour  had  first  been  noticed  in  the  epigastrium,  which  con- 
tinued to  increase  for  a  year,  and  since  then  had  been  stationary.  She 
had  suffered  from  dyspeptic  symptoms,  but  not  from  pain,  and  her 
general  health  had  1  een  good.  There  was  a  prominent  rounded  swell- 
ing extending  from  lower  end  of  sternum  to  below  umbilicus,  rather 
straight  on  either  side  apparently  from  contraction  of  recti  muscles. 
It  was  for  the  most  part  dull  on  percussion  ;  surface  smooth  and 
elastic,  bat  not  fluctuating ;  no  tenderness  except  at  one  spot  over 
ensiform  cartilage,  where  slightest  pressure  caused  much  pain.  The 
degree  of  bulging  varied  somewhat,  according  as  patient's  attention 
was  directed  to  it  or  not. 

On  Feb.   20  child  was  put  under  influence   of  chloroform ;  the 


LECT.  I.  CASES    OP    SIMULATED    ENLARGEMENT.  2/ 

tumour  disappeared,  and  no  turaonr  or  enlargement  of  liver  could  be 
felt.  When  the  effect  of  chloroform  passed  off,  tumour  returned  ;  but 
under  use  of  iron  and  belladonna  it  gradually  diminished,  and  several 
years  afterwards  she  vs^as  in  excellent  health. 

Case  yill.  illustrates  the  possibility  of  mistaking  a  large 
renal  cyst  ^  for  a  cystic  tumour  of  the  liver.  The  history  of  an 
injury  was  not  incompatible  with  hj'datid  of  the  liver,  for  in  many 
cases  of  hydatid  the  patients  date  their  origin  from  an  injury, 
which  has  been  the  means  of  drawing  attention  to  a  tumour 
already  existing.  There  was  no  history  of  hEematuria,  of  pus 
in  the  urine,  or  of  other  symptoms  of  urinary  disturbance,  such 
as  can  be  elicited  in  the  case  of  many  renal  cysts.  Unfor- 
tunately the  fluid  drawn  off  during  life  was  not  examined  for 
urea,  but  none  was  found  in  that  which  remained  in  the  sac 
after  death.  Moreover,  although  Mr.  Stanley  has  recorded  two 
cases  of  renal  cyst  where  the  fluid  contained  urea,^  none  has 
been  found  in  several  other  cases  which  are  on  record.^  Lastly, 
although  after  death  the  ascending  colon  and  coils  of  small 
intestine  were  found  in  front  of  the  cyst,  these  could  not  be 
made  out  before  paracentesis,  when  the  cyst  was  tense.  The 
operation  was  resorted  to  merely  as  a  palliative,  and  contri- 
buted in  no  way  to  the  fatal  result ;  the  inflammation  of  the 
sac  and  the  secondary  deposits  in  the  lungs  had  commenced 
previously. 

Case  VIII. — Enormous  Cystic  Tumour  communicating  with  Pelvis  of 
Bight  Kidneij,  existing  for  eight  years,  and  simulating  Hydatid  Tu- 
mour of  Liver. 

Joseph  0 ,  aged  16,  was  admitted  into  Middlesex  Hosp.  under 

my  care  Dec.  19,  1867.  Eight  years  before  he  had  been  thrown  with 
great  force  against  a  wall,  injuring  his  back  and  right  side.  For  a 
week  after  he  vomited  everything  he  swallowed,  and  altogether  he 
was  laid  up  for  two  months,  but  he  never  was  observed  to  pass  blood 
in  his  urine,  or  to  have  urinary  symptoms  of  any  sort. 

He  then  went  to  school  for  a  month,  when  he  was  seized  with 
severe  pain  in  his  back  and  right  side,  for  which  leeches  were  applied. 

'  Similar  cases  are  recorded  by  Mr.  Csesar  Hawkins  (Med.  Chir.  Trans.,  vol.  xviii. 
p.  175);  Mr.  Stanley  (ib.,  vol.  xxvii.  p.  1);  Sir  Henry  Thompson  (Path.  Trans.,  vol. 
xiii.  p.  12S);  and  Dr.  H.  Cooper  Rose  (Med.  Chir.  Trans,,  vol.  li.  p.  167). 

2  Med.  Chir.  Trans.,  1844,  vol.  xxvii.  p.  1. 

^  There  was  none  in  Dr.  Cooper  Rose's  case,  or  in  others  referred  to  by  Mr.  Spencer 
Wells  in  the  discussion  upon  Dr.  Rose's  case  at  the  Medico-Chirurgical  Society  on 
May  12,  1868. 


28  ENLARGEMENTS    OP    THE    LIVER.  lkct.  i. 

He  was  in  bed  for  five  months,  and  during  this  time  he  had  freqnent 
vomiting  and  nine  fits  of  convulsions,  the  movements  being  limited  to 
left  side  of  the  body.  Shortly  after  this  his  mother  noticed  that  his 
right  side  had  'grown  out,'  and  the  swelling  increasing  she  took  him 
to  the  London  Hospital,  where  he  remained  for  four  months,  and 
where  his  general  health  underwent  great  improvement.  His  health 
continued  good,  and  he  was  able  to  go  about,  but  the  swelling  slowly 
increased,  until  about  a  week  before  admission,  when,  after  getting 
thoroughly  wet  outside  a  cab,  he  was  seized  with  severe  pain  in  back, 
cough,  and  febrile  symptoms. 

On  admission,  patient  was  anfemic  and  emaciated,  and  complained 
of  cough  and  shortness  of  breath,  and  of  great  pain  and  tenderness  in 
lower  part  of  spine.  Pulse  108  ;  respirations  48  and  thoracic  ;  bron- 
chitic  rales  over  whole  of  both  lungs,  with  dulness  and  friction  over 
lower  fourth  of  left.  Tongue  clean  ;  appetite  bad;  temperature  101"4°. 
l^o  anasarca ;  and  urine  contained  no  albumen.  But  the  most  re- 
markable feature  about  the  boy  was  the  enormous  size  of  abdomen, 
which  measured  33^  inches  at  umbilicus,  the  bulging  being  greatest 
in  right  flank.  This  enlargement  was  almost  painless,  and  was  evi- 
dently due  to  an  encysted  collection  of  thin  fluid  on  right  side,  ex- 
tending from  liver  down  into  pelvis,  and  as  far  forwards  as  middle 
line,  but  clearly  shut  oS'from  general  cavity  of  peritoneum,  as  the  rest 
of  abdomen  was  tympanitic  in  whatever  position  patient  lay.  Hepatic 
dulness  ascended  to  nipple  in  front,  and  to  lower  angle  of  scapula 
behind. 

After  admission,  tumour  increased  in  size,  and  dyspncea  became  so 
urgent  that,  on  Dec.  23,  it  was  resolved  to  tap  cyst,  which  was  ac- 
cordingly done  by  Mr.  Hulke,  midway  between  ribs  and  crest  of  ilium, 
and  170  ounces  of  fluid  drawn  off.  The  fluid  which  first  came  away 
was  clear,  but  of  a  brownish  colour  ;  its  specific  gravity  was  1010,  and 
it  contained  much  chlorides,  and  about  one-sixth  of  albumen.  The 
last  two  pints  contained  much  pus,  forming  on  standing  a  creainy  de- 
posit, of  about  one-half  of  the  entire  bulk.  No  portion  of  the  fluid 
contained  either  echinococci  or  booklets. 

At  first  the  operation  was  followed  by  great  relief  to  d3'spna3a,  and 
at  no  time  afterwards  had  patient  either  rigors,  profuse  perspirations, 
pain  in  tumour,  or  albumen  in  urine.  The  prostration,  however,  in- 
creased daily ;  tongue  became  dry  ;  temperature  varied  from  100°  to 
103"2°  ;  much  restlessness  with  sleeplessness  and  occasional  delirium  ; 
and  the  signs  of  pleurisy  at  base  of  left  lung  noted  before  operation 
extended.     He  gradually  sank,  and  died  Jan.  2,  18G8. 

Autnpsy. — No  signs  of  recent  peritonitis,  but  on  right  side  of  ab- 
domen, lying  behind  intestines,  was  a  cyst,  with  thick  fibrous  walls, 
about  size  of  an  adult  human  head.  It  was  firmly  attached  by  fibrous 
adhesions  to  under  surface  of  liver,  to  false  ribs,  and  to  abdominal 
wall.     It  extended  downwards  to  brim  of  pelvis,  and  slightly  beyond 


r.ECT.  I.  CASES    OF    SIMULATED    ENLARGEMENT.  29 

middle  line  to  left.  Right  kidney  was  expanded  over  its  outer  and 
posterior  aspect,  and  the  renal  tissue  was  attenuated  and  wasted.  The 
sac  contained  65  ounces  of  thin  pus;  its  inner  wall  presented  a  fibrous 
puckered  aspect,  with  no  trace  of  hydatid  structure,  and  it  communi- 
cated by  three  openings,  oblique  and  valvular,  but  large  enough  to 
admit  a  full-sized  catheter,  with  pelvis  of  kidney.^  Right  ureter  was 
rather  small,  but  pervious  throughout ;  it  ran  for  some  distance  in 
wall  of  cyst  immediately  beneath  its  lining  membrane,  and  then  passed 
down  to  bladder,  which  was  quite  normal.  Upper  part  of  right 
kidney  was  converted  into  a  cicatrix-like  fibrous  tissue,  intimately  in- 
corporated with  cyst.  Left  kidney  was  double  normal  size,  but  other- 
wise normal.  Liver  fatty ;  spleen  very  large  and  soft.  Recent 
pleurisy  over  lower  lobe  of  left  lung,  which  contained  a  patch  of  red 
hepatisation ;  and  in  lower  lobe  of  right  lung  were  several  small 
patches  of  lobular  pneumonia,  with  yellow  centres,  l^o  pus  in  joints, 
and  no  sign  of  old  fracture  of  ribs,  or  of  disease  of  bodies  of  vertebrae. 

'  It  is  remarkable  that  notwithstanding  these  openings  the  urine,  up  to  the  day  of 
death,  never  contained  any  pus  or  a  trace  of  albumen.  A  similar  observation  was 
made  in  the  case  recorded  by  Mr.  Csesar  Hawkins  and  already  referred  to  (p.  27). 
In  that  case  also,  although  the  cyst  communicated  with  the  pelvis  of  the  right  kidney, 
no  urea  could  be  found  in  the  contained  fluid,  which  is  also  said  to  have  been  devoid 
of  albumen,  although  it  contained  pus. 


30  ENLARGEMENTS    OF    THE    LIVEPw 


LECTUEE   II. 
ENLARGEMENTS  OF  THE  LIVER. 

TETJE  ENLARGEMENTS  OF  THE  LIVER:  STJBBIVISION  INTO  PAINLESS  AND  PAINFUL:  1. 
THE  ■WAXY,  LARDACEOXJS,  OR  AMYLOID  LITER  ;  2.  THE  FATTY  LIVER  ;  3.  SIMPLE 
HYPERTROPHY. 

Bearing  in  mind  the  various  circumstances  under  which  I  have 
told  you  that  liypertrophy  of  the  liver  may  be  simulated  during 
life,  we  are  now  prepared  for  considering  those  cases  in  which 
an  increased  area  of  hepatic  dulness  is  due  to  real  enlargement 
of  the  organ.  And  first  of  all  it  may  be  observed  that  enlarge- 
ment is  a  character  common  to  many  different  diseases  of  the 
liver,  so  that  some  classification  will  be  a  material  aid  in  dia- 
gnosis. The  late  Dr.  Bright,  whose  researches  on  diseases  of  the 
abdomen  are  scarcely  less  valuable  than  those  on  diseases  of 
the  kidneys,  with  which  his  name  will  for  ever  be  associated, 
divided  enlargements  of  the  liver  into  two  classes,  according  as 
their  form  was  smooth  or  irregular.^  But  this  subdivision  is,  in 
my  opinion,  open  to  the  objection  that  in  certain  diseases  (e.g. 
waxy  liver)  an  enlargement  which  is  usually  regular  and  smooth 
may  assume  a  lobular  or  nodulated  character,  whereas  in  others 
(e.g.  cancer)  an  enlargement  which  is  for  the  most  part  nodu- 
lated, may  occasionally  be  perfectly  smooth.  A  subdivision 
which  appears  to  me  to  be,  on  the  Avhole,  preferable,  is  that 
into  'painless  and  painful  enlargements.  Painless  enlargements 
are  further  characterised  by  an  absence  of  jaundice  and  ascites, 
and  by  a  chronic  course  ;  but  in  painful  enlargements  jaundice 
and  ascites  are  common  symptoms  and  the  progress  is  more 
rapid. 

Among  painless  enlargements  we  have  the  so-called  amy- 
loid liver,  the  fatty  liver,  hydatid  tumour  of  the  liver,  and 
simple  hypertrophy. 

Among  enlargements  in  which  pain  is  a  prominent  symptom 

Abdominn,!  Tumours.     Syd.  Soc.  ed.  p.  242. 


WAXT    LIVEE. 


31 


we  have  congestion,  catarrh  of  the  bile-ducts,  obstruction  of 
the  common  duct  and  retention  of  bile,  interstitial  hepatitis, 
pysemic  abscesses,  tropical  abscess,  and  cancer. 

There  are  other  enlargements  of  the  liver  besides  those  now 
mentioned,  such  as  tubercle,  spindle-cell  sarcoma,  etc.,  the 
anatomical  and  clinical  characters  of  which  are  less  known. 
I  purpose  in  a  separate  lecture  to  bring  some  of  these  rarer 
forms  of  enlargement  under  your  notice,  but  in  the  first  place 
we  may  consider  in  detail  the  distinguishing  characters  of  the 
several  forms  of  enlargement  with  which  we  are  best  acquainted. 

I.    THE    WAXT,    LARDACEOUS,    OR    AMYLOID    LIVER. 

The  liver  undergoes  greater  enlargement  from  the  so-called 
waxy,  or  amyloid,  deposit,  than  from  any  other  disease,  except- 
ing, perhaps,  cancer.  I  have  known  the  liver  of  an  adult 
affected  with  this  disease  weigh  upwards  of  180,  instead  of  50 
or  60  ounces ;  and  the  liver,  of  which  I  show  you  here  a  por- 
tion, weighed  one-seventh,  instead  of  a  twenty-fifth,  of  the 
entire  body  of  the  child  from  Avhich  it  was  taken.  Enlarge- 
ment of  the  liver  due  to  waxy  or  amyloid  deposit  may  be  re- 
cognised during  life  by  the  following  characters  : — 

1.  The  enlargement  is  often  great,  so  that  the  liver  fills  up 
a  large  portion  of  the  abdominal  cavity. 

2.  It  is  uniform  in  every  direction,  so  that  the  form  of  the 
organ  is  not  essentially  altered.  The  area  of  hepatic  dulness 
on  percussion  is  increased  in  the  median,  dorsal,  and  axillary 
lines,  as  well  as  in  the  right  mammary.  The  increase  is  greater 
in  front  than  behind,  because  in  the  former  situation  there  is 
greater  room  for  growth  (figs.  10  and  11).  It  is  increased  in 
an  upward  as  well  as  in  a  downward  direction,  although  mainly 
in  the  latter,  the  lower  margin  often  reaching  the  umbilicus,  or 
even  the  right  groin ;  but  nowhere  is  there  any  outgrowth 
from  the  normal  contour.  The  abdomen  is  enlarged,  and  often 
there  is  a  visible  bulging  below  the  right  costal  arch  and  in  the 
epigastrium,  but  rarely,  if  ever,  is  there  any  bulging  of  the 
ribs  themselves;  for  waxy  enlargement  of  the  liver  moulds 
itself  over  adjacent  organs,  and  has  little  tendency  to  cause 
displacement  of  the  ribs  by  excentric  pressure. 

3.  On  palpation,  the  portion  of  liver  which  extends  below 
the  margin  of  the  ribs  is  very  dense,  firm,  and  resisting. 
There  is  no  elasticity,  and  still  less  any  feeling  of  fluctuation. 


32 


ENLAKGEMENTS    OF    THE    LIVER. 


4.  The  outer  surface  is  smootli,  and  the  lower  margin  is 
somewhat  more  rounded  than  natural,  regular,  and  free  from 
indentation.  In  this  respect,  however,  rare  exceptions  occur, 
an  ignorance  of  which  may  lead  to  errors  in  diagnosis.  Occa- 
sionally waxy  deposit  in  the  liver  coexists  with  cirrhosis,  or  with 
what  are  known  as  syphilitic  cicatrices,  and  then  the  surface  of 
the  organ  may  be  nodulated,  or  even  broken  up  into  irregular 


Fig.  10  shows  the  increased  area  of  hepatic 
and  of  splenic  dulness  in   the   case   of 

Henry  D :  anterior  view.     Between 

the  two  is  a  space  yielding  the  clear 
tympanitic  sound  of  tlio  stomach;  and 
above  the  liver  is  the  normal  area  of 
cardiac  dulness.  Compare  this  with 
fig.  3,  wliich  shows  the  normal  boun- 
daries of  the  liver  and  .spleen. 


Fig.  11  shows  the  increased 
area  of  hepatic  dulness 
in  Henry  D :  view  on 


right    side, 
border     is 
gradually 
the  spine, 
with  fig.  4. 


The    upper 

arched,     and 

falls     towards 

Compare  this 


lobes,  separated  by  deep  fissures,  the  existence  of  which  may 
lead  to  the  suspicion  that  the  enlargement  is  due  to  cancer. 
In  cases  also  of  extreme  enlargement  there  may  be  an  exaggera- 
tion, so  to  speak,  of  the  lobes  into  which  the  liver  is  naturally 
divided,  deep  fissures  corresponding  to  the  attachment  of  the 
ligaments.  Some  years  ago  I  had  an  opportunity  of  observing 
a  case  of  this  sort  under  the  care  of  Dr.  Greenhow  in   the 


LECT.  n.  WAXY   LIVER.  33 

Middlesex  Hospital,  the  particulars  of  whicli  I  shall  relate  to 
you  presently.  Cases  have  also  been  recorded  by  Professor 
Frerichs,  of  Berlin,  in  which  a  waxy  liver  has  presented  a  more 
or  less  lobnlated  form. 

5.  Waxy  deposit  in  the  liver  has  but  little  tendency  to 
obstruct  the  portal  circulation,  and  consequently  ascites  and 
enlargement  of  the  subcutaneous  veins  of  the  abdominal  wall 
are  not  common  phenomena  in  its  clinical  history.  When  such 
indications  of  portal  obstruction  do  occur,  they  are  usually  due 
to  pressure  exerted  on  the  trunk  of  the  portal  vein  by  lymphatic 
glands  in  the  fissure  of  the  liver  enlarged  from  waxy  deposit. 
Occasionally,  also,  fluid  is  effused  into  the  peritoneum  as  the 
result  of  general  anaemia,  concurrent  disease  of  the  kidneys, 
or  secondary  peritonitis. 

6.  Jaundice  also  is  a  rare  symptom  in  waxy  disease  of  the 
liver ;  and  when  it  occurs,  it  is  due,  for  the  most  part,  to  the 
pressure  on  the  bile-ducts  of  enlarged  lymphatic  glands,  or  to 
the  co-existence  of  catarrh  of  the  bile-ducts. 

7.  Pain  and  tenderness  are  never  prominent  symptoms. 
The  liver  can  be  manipulated  with  impunity  and  the  patient 
complains  only  of  a  feeling  of  weight  or  tightness  in  the  right 
hypochondrium,  or  of  uneasiness  from  the  pressure  to  which 
the  stomach  and  intestines  are  subjected.  But  occasionally, 
and  particularly  where  there  is  a  syphilitic  history,  there  is  an 
attack  of  acute  pain  from  intercurrent  peri-hepatitis.  In  the 
patient  now  under  your  notice,  with  paralysis  of  the  right  fifth 
nerve  from  syphilitic  disease,^  the  liver  and  spleen,  which  are 
much  enlarged  from  waxy  deposit,  were  intensely  tender  for  a 
time,  owing  to  inflammation  of  their  peritoneal  covering  ;  and 
in  another  case  which  I  met  with  some  years  ago  (Case  X.),  the 
enlargement  commenced  in  India  with  severe  pain  in  the  right 
side,  for  which  numerous  leeches  were  applied,  but  the  en- 
larged liver  subsequently  exhibited  its  usual  painless  character. 
Prerichs  also  has  recorded  a  case  where  waxy  liver  supervened 
on  protracted  ague,  and  where  '  the  first  symptom  was  persis- 
tent cutting  pains  in  the  side.'^  Lastly,  the  presence  of  acute 
tenderness  in  waxy  disease  of  the  liver  from  the  concurrence  of 
peri-hepatitis  was  demonstrated  in  Case  XI.  by  post-mortem 
examination. 

'  Case  in  St.  Thomas's  Hospital,  November,  1875. 
2  Diseases  of  the  Liver,  Syd.  Soc.  Transl.  vol.  ii.  p.  200. 
D 


34  ENLAEGEMENTS   OF   THE    LIVER.  lect.  it. 

8.  The  growth  of  tlie  tumour  is  slow  and  imperceptible.  It 
often  extends  over  several  years. 

9.  Constitutionally,  the  symptoms  are  chiefly  those  of 
anajmia.  Thei'e  is  no  pyrexia ;  but  the  countenance  is  pale  and 
sallow,  the  patient  suffers  from  general  debility,  and  the  propor- 
tion of  white  corpuscles  in  the  blood  is  somewhat  increased. 

Other  characters  of  no  small  moment  in  diagnosis  are  de- 
rived from  the  spleen,  the  kidneys,  the  stomach,  or  the  intes- 
tines being  the  seat  of  a  similar  morbid  deposit  to  that  pro- 
ducing the  hepatic  enlargement. 

10.  The  spleen  in  most  cases  is  enlarged,  and  often  greatly, 
as  well  as  the  liver.  The  enlargement,  like  that  of  the  liver,  is 
uniform,  hard,  smooth,  and  painless. 

11.  As  a  rule,  waxy  disease  produces  enlargement  of  the 
liver  before  there  is  any  evidence  of  its  existence  in  the  kid- 
neys. Wetzlar  found  no  albumen  in  the  urine  of  any  one  of 
18  patients  suffering  from  syphilitic  waxy  enlargement  of  the 
liver.'  When  present,  waxy  disease  of  the  kidneys  has  charac- 
ters of  its  own,  the  presence  of  which  in  any  case  of  hepatic 
enlargement  would  alone  make  it  very  probable  that  this  en- 
largement was  due  to  waxy  dejjosit.     These  characters  are  : — 

a.  An  increased  quantity  of  urine.  Not  uncommonly  the 
patient  voids  from  three  to  five  pints  of  urine  in  the  twenty- 
four  hours.  This  is  the  rule  throughout  the  greater  part  of 
the  course  of  the  disease.  Towards  the  termination  only  is  the 
quantity  diminished.^ 

h.  The  urine  is  of  a  pale  lemon  colour,  of  moderately  low 
specific  gravity  (about  1014),  free  from  any  smokiness,  and  con- 
tains a  considerable  amount  of  albumen.  In  the  early  stage, 
however,  there  may  be  no  albuminuria  (Case  XI.). 

c.  Casts  of  the  renal  tubes  are  often  absent.  When  present, 
the}'  may  be  of  an  epithelial  or  hyaline  character,  usually  the 
latter,  and  most  of  them,  from  their  size,  appear  to  have  come 
from  tubes  not  denuded  of  their  epithelium.  These  hyaline 
casts,  so  far  as  my  observation  goes,  never  yield  the  so-called 
amyloid  reaction  with  iodine  and  suliDhuric  acid ;  but  in  excep- 
tional cases  this  reaction  may  be  observed  in  some  of  the  cast- 
off  renal  cells. 

'  'Glasgow  Med.  Journal.'  May,  1869. 

'  To  Dr.  fJraiiiL'or  Stewart,  of  Ediiilnirprli,  wc  are  mainly  indebted  for  pointing 
out  the  characters  of  the  urine  in  waxy  disease  of  the  kidneys.  My  own  obser\ation.s 
coincide  with  his  in  every  essential  point. 


tECT.  n.  "WAXY   LIVER.  35 

d.  During  the  greater  part  of  the  disease,  when  the  urine 
is  increased  in  quantity,  there  is  no  material  diminution  in  the 
excretion  of  urea,  and  consequently  the  tendency  to  ursemia  is 
much  less  than  in  other  forms  of  kidney  disease.  Even  in  the 
advanced  stage  ursemic  symptoms  are  comparatively  rare,  and 
death  is  more  often  the  result  of  an  exhausting  diarrhoea.  • 

e.  According  to  Warburton  Begbie,  the  urine  contains 
uroxanthin  in  greater  or  less  quantity,  and  when  treated  with 
an  acid  or  exposed  to  the  air,  there  is  developed  in  it  an  indigo- 
blue,  or  indigo-red.' 

The  persistent  secretion  of  a  large  quantity  of  urine  con- 
taining much  albumen  by  a  person  who  has  never  had  general 
anasarca  will  of  itself  warrant  the  presumption  that  he  is 
suffering  from  waxy  disease  of  the  kidneys.  In  the  contracted 
or  gouty  kidney  there  may  also  be  no  dropsy,  and  the  quantity 
of  urine  may  be  increased ;  but  here  the  specific  gravity  is 
remarkably  low  (often  not  exceeding  1010  or  1005)  and  al- 
bumen is  usually  present  as  a  mere  trace,  or  may  be  entirely 
absent. 

12.  The  implication  of  the  stomach  and  intestines  in  the 
waxy  disease  induces  a  tendency  to  vomiting  and  to  obstinate 
diarrhoea  from  slight  causes.  Occasionally  this  diarrhoea  is 
accompanied  by  tenesmus,  and  the  patient  may  be  thought  to 
labour  under  dysentery  ;  but  post-mortem  examination  reveals 
no  evidence  of  inflammation  of  the  bowel. 

13.  The  breath  and  skin  in  advanced  cases  often  exhale  a 
disagreeable  odour,  which  is  characteristic,  and  which  Begbie 
has  likened  to  that  of  musty  indigo. 

14.  Here,  as  in  many  other  maladies,  the  circumstances 
under  which  the  disease  usually  makes  its  appearance  are  of 
considerable  importance  in  diagnosis.  There  are  certain  con- 
ditions which  pre-eminently  favour  the  advent  of  waxy  disease. 
Among  them  may  be  mentioned  the  following  : — 

a.  Long-standing  purulent  discharge,  such  as  is  particu- 
larly apt  to  happen  in  connection  with  diseased  bones  or  joints, 
dysentery,  tubercular  cavities  in  the  lungs,  and  after  surgical 
operations  when  the  wound  does  not  readily  heal.  In  several 
cases  of  syphilitic  ozsena  I  have  met  with  waxy  disease  of  the 
liver  and  other  organs  (Case  XII.). 

b.  Constitutional  syphilis.  In  a  large  number  of  cases  of 
waxy  disease  the  patients  have  been  the  subjects  of  constitu- 

»  Eeynolds's  Syst.  of  Med.  iii.  966. 
D  2 


36  ENLARGEMENTS    OF    THE    LIVER.  lect.  ii. 

tional  syphilis,  which  appears  to  act  as  a  predisposing  cause 
independently  of  its  inducing  disease  of  the  bones  or  protracted 
discharges,  and  independently  of  any  abuse  of  mercury  to 
which  waxy  liver  was  attributed  by  Graves  and  G.  Budd. 

c.  Tubercle  of  the  lungs  and  of  other  organs  must  be  re- 
garded as  a  predisposing  cause  of  waxy  degeneration,  although 
the  enlargement  of  the  liver  common  under  such  circumstances 
is  oftener  fatty  than  waxy.  Of  52  cases  of  persons  dying  from 
tubercle,  and  whose  autopsies  I  have  recorded,  the  liver  was 
fatty  in  20,  and  waxy  in  6,  and  in  3  of  the  6  there  was  like- 
wise caries  of  the  bones.  Still,  of  the  52  cases,  14  had  waxy 
disease  of  either  the  kidneys,  the  liver,  or  the  spleen,  or  1  in 
3^.  The  proportion  of  tubercular  males  in  whom  waxy 
disease  was  found  was  more  than  double  that  of  females. 
Thus,  of  33  tubercular  males,  there  was  waxy  disease  in  11,  or 
1  in  3 ;  whereas  of  19  tubercular  females,  only  3,  or  1  in  6^ 
had  waxy  disease.  It  should  be  added  that  waxy  disease  from 
all  causes  is  much  more  common  among  males  than  among 
females.     Of  68  cases  collected  by  Frerichs,  53  were  males. 

d.  Many  chronic  diseases  which  impair  the  general  nutri- 
tion seem  to  predispose  to  waxy  degeneration,  which  has  thus 
been  met  with  as  a  sequel  of  protracted  ague,^  cancer,  &c. 

Treatment. — The  following  rules  comprise  those  measures 
which  experience  has  shown  to  be  most  useful  in  the  treatment 
of  waxy  disease  of  the  liver.  In  many  cases,  unfortunately, 
when  the  disease  is  already  in  an  advanced  stage,  and  when 
the  kidneys  and  intestines  are  involved  in  the  waxy  degenera- 
tion, all  treatment  is  of  little  avail,  and  the  patient  dies  of 
exhaustion,  wliich  may  be  oftea  ascribed  to  the  copious  drain 
of  albumen  in  the  urine  or  to  the  occun-ence  of  profuse  diarrhoea 
(as  in  Case  XIII.).  But,  on  the  other  hand,  in  not  a  few  cases 
the  progress  of  the  disease  appears  to  be  arrested  by  appro- 
priate treatment,  and  in  some,  as  in  Case  X.,  there  is  reason 
for  believing  that  the  waxy  deposit  may  be  in  great  measure 
removed.  In  any  case  the  danger  is  great  in  proportion  to 
the  extent  to  which  the  kidneys  and  intestines  are  involved. 

I.  Prevention. — The  prevention  of  diseases  in  general  has 
not  yet  received  from  the  practical  physician  the  attention 
which  it  deserves.  The  more  we  study  the  causes  of  disease, 
the  more  apparent  it  is  that  we  possess  a  power  in  this  direc- 
tion which  has  hitherto  been  too  much  neglected.     Bearing  in 

'  See  Lecture  IV. 


LECT.  II.  WAXY   LIVEE.  3/ 

mind  the  causes  whicli  we  have  found  to  lead  to  waxy  en- 
largement of  the  liver,  the  means  for  its  prevention  will  at 
once  suggest  themselves.  First  and  foremost,  it  is  always 
advisable  to  arrest  as  early  as  possible  copious  suppuration 
from  any  part  of  the  body,  and  in  particular  from  diseased 
bone,  and,  if  necessary,  to  have  recourse  to  surgical  interference 
for  this  purpose.  It  ma}^  indeed  be  a  question  whether  some 
of  those  operations,  which  what  is  called  '  conservative  surgery  ' 
has  of  late  years  substituted  for  amputation,  from  entailing 
protracted  suppuration,  have  not  sacrificed  the  life  of  the 
patient  to  the  endeavour  to  save  his  limb.  The  death  of  the 
patient  is  ascribed  to  a  bad  constitution,  which  may,  however, 
possibly  be  the  result  of  internal  disease  engendered  by  the 
operation.  In  cases  where  the  disease  of  the  liver  comes  on 
in  the  course  of  phthisis,  our  treatment  must  be  directed  to 
the  primary  disease,  and  every  means  should  be  employed  to 
arrest  the  purulent  discharge  from  the  lungs,  the  diarrhoea, 
and  the  exhausting  sweats^  Again,  the  symptoms  of  constitu- 
tional syphilis  must  always  be  met  by  appropriate  treatment,, 
and  measures  must  be  taken  to  prevent  the  condition  of 
general  cachexia  which  is  apt  to  supervene  on  such  exhausting 
diseases  as  ague  and  dysentery.  Lastly,  it  may  be  mentioned 
that  in  cases  where  there  is  a  copious  suppurative  drain  from 
the  system,  alkalies. have  been  proposed  as  a  means  of  prevent- 
ing the  waxy  deposit.  Chemistry  is  said  to  have  shown  that 
the  waxy  material  is  dealkalised  fibrin ;  and  it  is  argued  that 
as  a  large  quantity  of  alkali  passes  off  with  the  pus,  the  waxy 
deposit  may  be  prevented  by  restoring  this  alkali  to  the 
system.^ 

II.  When  waxy  disease  is  already  present,  we  must  combat 
it  by  such  measures  as  the  following  : — 

1.  The  diet  ought  to  be  of  as  nutritious  a  character  as  is 
compatible  with  the  digestive  powers  of  the  individual.  A 
moderate  allowance  of  alcoholic  stimulants  is  generally  useful. 
Considering  the  ansemic  condition  of  the  liver,  alcohol  is  less 
likely  to  be  injurious  than  in  most  other  enlargements  of  the 
organ.  When  the  disease  is  not  too  far  advanced,  and  when 
the  means  of  the  patient  permit,  removal  to  a  mild  and 
equable  climate  is  generally  advisable. 

2.  Alkalies. — From  my  own  experience  I  am  not  in  a  posin 
tion  to  make  any  dogmatic  statement  as  to  the  effects  of  alka- 

>  Dr.  Dickinson,  Med.-Chir,  Trans.  Vol.  L.  p.  55. 


38  ENLAEGEMENTS    OF   THE    LIVEE.  lect.  ii. 

lies  in  waxy  disease,  but  I  am  assured  by  Dr.  Dickinson  that 
not  only  in  cases  of  purulent  discharge  from  diseased  bone 
has  he  found  that  the  salts  of  potash  compensate  for  the  dis- 
charge and  prevent  waxy  disease,  but  that  he  has  also  known 
patients  with  advanced  waxy  disease  of  the  liver  and  albumi- 
nous urine  get  better  under  their  use.  The  treatment  is  one 
which  certainly  deserves  a  trial,  and  you  may  prescribe  a 
mixture  containing  the  liquor  potassse  with  the  phosphate  and 
citrate  of  potash  and  tartrate  of  iron. 

3.  Tonics. — Most  patients  suffering  from  waxy  disease 
derive  benefit  from  the  use  of  tonics,  and  particularly  from 
the  various  preparations  of  iron,  such  as  the  perchloride  and 
the  iodide.  In  more  than  one  case  I  have  known  marked  im- 
provement take  place  under  the  continued  use  of  nitric  acid, 
in  combination  with  such  vegetable  bitters  as  gentian  or 
quinine.  The  external  use  of  nitro-muriatic  acid  in  the  way 
to  be  described  to  you  in  a  future  lecture  (Lect.  IV.)  also  de- 
serves a  ti-ial.  Cod-liver  oil  is  of  questionable  utility  ;  Frerichs 
states  that  he  has  known  cases  where  waxy  liver  was  developed 
under  its  continuous  use. 

4.  Iodine  and  its  preparations  are  of  undoubted  utility  in 
the  treatment  of  waxy  disease,  and  particularly  when  there  is 
a  clear  syphilitic  history.  No  preparation,  I  believe,  is  supe- 
rior in  this  respect  to  the  tincture  of  iodine  of  the  British 
Pharmacopoeia,  which  may  be  given  in  doses  of  10  or  15 
minims,  diluted,  three  or  four  times  a  day.  You  will  remem- 
ber the  marked  improvement,  not  only  in  the  general  symptoms, 
but  in  the  size  of  the  liver,  which  took  place  under  its  use  in 
the  case  of  H.  D.  (Case  X.).  In  cases  with  a  syphilitic  history 
great  benefit  is  also  said  to  be  derived  from  small  doses  of 
perchloride  of  mercury  in  conjunction  with  the  baths  and 
mineral  waters  of  Aix-la-Chapelle.^ 

5.  Budd  ^  has  observed  cases  where  a  marked  improvement 
with  diminution  in  the  size  of  the  liver  has  occurred  under 
the  use  of  the  salts  of  ammonia,  such  as  the  carbonate  and 
the  chloride.  In  one  case  where  the  chloride  of  ammonium 
was  given  in  doses  of  from  5  to  10  grains  three  times  a  day, 
a  great  enlargement  of  the  liver,  which  had  existed  for  nine 
months,  and  was  accompanied  by  emaciation,  pallor,  and  irri- 
tative fever,  and  where  mercury,  iodine,  taraxacum,  and  nitro- 
muriatic  acid  had  been  tried  in  turn  without   success,   was 

'  Wetzliir,  loc.  cit.  -  Dis.  of  Liver,  3vd  ed.  p.  335. 


LECT.  n.  WAXY    LIVEE.  39 

entirely  reduced.  Warburton  Begbie  also  has  observed  a  great 
reduction  in  waxj  enlargement  of  the  liver  effected  bj  chloride 
of  ammonium,  in  doses  of  from  15  to  30  grains  thrice  daily. ^ 

6.  In  all  cases  of  waxy  liver,  you  must  be  on  the  look-out 
for  complications,  and  meet  them  when  they  arise.  Those 
which  you  have  chiefly  to  expect  are  diarrhoea,  vomiting, 
albuminuria,  dropsy,  and  uraemia.  The  diarrhoea  must  be 
met  by  mineral  and  vegetable  astringents  with  opium,  the 
pernitrate  of  iron,  and  counter-irritation  to  the  abdomen. 
Even  in  cases  where  the  kidneys  are  involved,  opium  is  less 
to  be  dreaded  than  in  other  forms  of  kidney  disease.  But  not 
unfrequently  the  diarrhoea  resists  all  treatment  and  cuts  off 
the  patient.  Persistent  vomiting  also  is  a  serious  complication, 
and  is  often  unaffected  by  treatment;  ice,  bismuth,  hydro- 
cyanic acid,  and  counter- irritation  to  the  epigastrium  are  the 
most  useful  remedies.  The  albuminuria  requires  no  special 
treatment  apart  from  that  of  the  diseased  liver.  Dropsy  must 
be  met  by  diaphoretics  and  diuretics,  the  liquor  ammonise 
acetatis  with  warm  baths,  and  the  bitartrate  or  acetate  of 
potash  with  digitalis.  With  these  remedies  it  will  be  well  to 
combine  the  salts  of  iron,  such  as  the  perchloride  with  the 
liquor  ammon.  acetat.,  or  the  acetate  of  iron  with  the  acetate 
of  potash.  Drastic  purgatives  must  always  be  given  with 
caution  in  this  form  of  dropsy,  for  fear  of  inducing  uncon- 
trollable diarrhoea.  Lastly,  in  those  rare  cases  where  ursemia 
occurs  towards  the  close  of  the  disease,  the  remedies  indicated 
are  diaphoretics,  the  vapour  bath,  diuretics,  and,  if  necessary, 
a  brisk  purgative. 

In  illustration  of  the  remarks  now  made  I  show  you  in  the 
first  place  a  portion  of  the  liver  which  I  removed  from  the 
body  of  a  patient  who  died  in  the  Middlesex  Hospital  some 
years  ago,  and  in  whom  the  clinical  history  and  post-mortem 
appearances  were  as  follows  : — 

Case    IX. — Caries  of  Hip-joint — Waxy  Liver,  weighing  nearly  one- 
seventh  of  entire  body — Waxy  Spleen — Fatty  Kidneys. 

H.    L ,    aged    7,    adm.    into   Middlesex   Hosp.    under   care  of 

Mr.  Shaw,  Nov.  30,  1858,  having  suffered  from  disease  in  left  hip- 
joint  for  about  nine  months.  He  was  emaciated  and  of  scrofulous 
habit,  head  and  joints  being  large  in  proportion  to  rest  of  body. 
Considerable  pain  in  left  hip,  increased  on  movement,  so  that  he 
walked  with  difficulty.  Soon  after  admission,  abscesses  opened  iu 
'  Eeynokls's  System  of  Medicine,  iii.  968. 


40  ENLAEGEMENTS    OP   THE    LIVER.  lect.  ii. 

neighbourLood  of  left  hip,  and  sinuses  continued  to  discharge  until  his 
death  on  Jan.  27,  1861.  During  life  there  was  great  tumidity  of 
abdomen,  obviously  due  to  enlargement  of  liver,  lower  margin  of 
-which  extended  to  below  umbilicus,  and  surface  of  which  was  dense, 
smooth,  and  painless.  Splenic  dulness  also  increased,  and  the  boy 
passed  urine  containing  much  albumen,  but  he  had  no  dropsy.  He 
was  also  liable  to  intercurrent  attacks  of  diarrhoea,  and  tongue  was 
preternaturally  clean,  red,  and  glazed. 

Post-mortem  examination. — Body  extremely  emaciated,  joints  being 
large  in  proportion  to  limbs.  Total  weight  of  body  only  311b.  3oz., 
or  499  oz.  avoird. ;  length  of  body  was  3^  ft.  Abdomen  remarkably 
tumid  and  hard,  particularly  in  right  hypochondrium.  Much  swelling 
about  left  hip-joint,  with  numerous  sinuses  passing  into  bone.  Left 
thigh  flexed  forwards  and  immovable.  Entire  head  of  left  femur 
absent,  and  end  of  bone  carious;  acetabulum  likewise  diseased,  bone 
being  exposed  and  carious,  and  at  one  part  deficient,  so  that  there  was 
an  opening  into  pelvic  cavity. 

Head  was  rem ai'kably  large,  its  circumference  being  21-^  in.  Brain 
weighed  55-|  oz. ;  its  structure  normal.  Each  of  lateral  ventricles 
contained  three  drachms  of  serum,  and  at  base  were  two  fluid  ounces. 
Membranes  normal. 

Heart  and  lungs  normal. 

Liver  enormously  enlarged  and  very  dense.     Its  weight  was  09  oz. 
avoird.,  or  nearly  one-seventh  of  weight  of  whole  body,  the  normal 
ratio  for  a  child  nine  years  of  age  being  only  about  1  to  25.    It  reached 
as  far  as  umbilicus,  and  moulded  itself  over  the  different    organs  in  its 
vicinity.     Its  tissue  was  very  firm,  so  that  the  organ  retained  its  form 
when  laid  with  its    convex    surface    on    table.     Its   external   surface 
perfectly  smooth  and  free  from  all  adhesions,  but  exhibited  impres- 
sions  of   adjacent   organs.      Its  cut  surface  was  of    a  grayish-pink 
colour  and  translucent,  and  presented  a  network  of  opaque  yellowish 
streaks  composed  of  fibrous  tissue,  apparently  corresponding  to  outline 
of  enlarged  lobules,  and  enclosing  the  firm  translucent  material  in  its 
meshes.     Iodine  and  sulphuric  acid  developed  the  so-called  amyloid 
reaction  in  a  marked  degree.     On  microscopic  examination,  the  hepatic 
cells  appeared  to  be  coherent  into  flat  scales,  and  could  not  be  isolated. 
The   nuclei  were  distinct,    but  outlines    of  cell-walls    were   scarcely 
appreciable  at  many  places,  the  nuclei  appearing  interspersed  through 
a   translucent  homogeneous  mass :    at    some  places  even  the  nuclei 
could  not  be   distinguished.      Towards   circumference  of  lobules  the 
cells  were  more  distinct,  and  at  some  places  contained  an  unusual 
amount  of  oil. 

Spleen  weighed  II']  oz.,  and  2)rescnted  a  dense,  glistening  surface 
on  section,  which  became  deeply  tinged  when  treated  with  iodine  and 
sulphuric  acid. 

Kidneys  large,  right  weighing  o  oz.,  and  left  5^  oz.     They  were  not 


I.ECT.  11.  WAXY    LIVER.  4 1 

at  all  dense,  but,  on  the  contrary,  very  flabby.  Their  capsules  were 
non-adherent,  and  surfaces  "were  perfectly  smooth  and  pale  yellow, 
with  a  network  of  injected  veins.  Cortical  substance  hypertrophied, 
pale  yellow,  opaque,  and  soft.  Renal  epithelium  throughout  kidneys 
loaded  with  fine  molecules  and  oil- globules,  and  at  many  places 
uriniferous  tabes  appeared  blocked  up  with  oil.  Iodine  and  sulphuric 
acid  produced  a  decided  tinging  of  minute  arteries  and  Malpighian 
bodies  in  cortex. 

Mesenteric  and  Peyerian  glands  slightly  enlarged,  and  the  applica- 
tion of  iodine  to  mucous  membrane  of  the  bowel  jaroduced  numerous 
brownish-red  puncta,  corresponding  to  the  villi. 

The  co-existence  of  fatty  kidneys  with,  waxy  disease  of  the 
liver  and  spleen,  in  this  case,  is  worthy  of  notice.  It  is  to  be 
observed,  however,  that  even  in  the  kidneys  the  minute  vessels 
yielded  the  so-called  amyloid  reaction. 

Many  of  you  have  had  an  opportunity  of  examining  the 
patient  whose  case  I  am  now  about  to  relate. 

Case  X. — Constitutional  Syphilis,  folloived  by  Symptoms  of  Waxy 
Disease  of  Liver,  Spleen,  and  Kidneys, 

H.   D ,  aged  28,  adm.  Dec.  27,  18G6,  into  Middlesex  Hosp. 

As  a  young  man  he  appears  to  have  enjoyed  good  health,  and  to  have 
been  temperate.  But  six  years  ago  he  contracted  syphilis,  followed 
by  buboes,  which  were  opened,  and  scars  are  still  visible  in  groins. 
Wound  soon  healed  up,  discharging  only  for  about  two  weeks.  He 
does  not  remember  having  had  sore-throat  or  pains  in  bones.  In  1858 
he  joined  a  cavalry  regiment  in  India.  With  the  exception  of  one  or 
two  slight  attacks  of  diarrhoea,  his  health  still  kept  good  until  about 
Nov.  1864,  when  he  was  seized  with  pain  in  right  hypochondvium, 
which  confined  him  to  bed  for  six  weeks.  The  pain  was  increased  on 
taking  a  long  inspiration  ;  and  he  had  leeches  and  blisters  applied. 
At  end  of  six  weeks  he  returned  to  his  duty  ;  but  his  liver  enlarging  and 
his  strength  failing,  he  was  discharged  from  the  service,  and  arrived 
in  England  in  June  1865.  Since  his  return  to  England  he  has  been  able 
to  earn  his  living  as  a  labourer  ;  but  he  has  suffered  each  winter  from 
cough,  and  expectoration  occasionally  slightly  streaked  with  blood. 
Eight  weeks  before  admission  he  lost  his  appetite  and  strength,  and  was 
sent  as  a  case  of  '  fever  '  to  London  Fever  Hospital,  where  he  took  mer- 
cury and  iodide  of  potassium,  with  the  object  of  reducing  size  of  liver. 
On  leaving  the  Eever  Hospital  he  came  here.  He  does  not  remember 
having  had  any  form  of  fever  in  India,  and  at  no  time  of  his  life  has 
he  had  dropsy  in  any  part  of  his  body. 

On  admission,  patient  was  thin  and  anaemic,  and  had  a  decided 
sallowness  of  countenance,  without  any  jaundiced  tint  of  conjunctivae. 


42  ENLARGEMENTS    OF   THE    LIVER.  lect.  ii. 

Over  back  were  numerous  small  scars  and  cojoper-coloured  discoloura- 
tions.  But  what  was  most  remarkable  Avas  the  enlargement  of  liver, 
upper  margin  of  which  rose  as  high  as  fourth  intercostal  space,  while 
lower  margin  reached  as  low  as  lower  edge  of  umbilicus  (see  fig.  10, 
p.  32).  The  organ  appeared  large  in  every  direction,  its  dimensions 
being  as  follows  :  In  median  line,  8j  in. ;  in  right  mammary  line,  9|  in. ; 
in  x'ight  axillary,  fi^iu.;  in  right  dorsal,  5^  in.  The  upper  margin 
of  hepatic  dulness  was  arched  (fig.  11),  that  in  axillaiy  line  being  an 
inch  lower  than  in  right  mammaiy ;  in  right  dorsal  line  it  rose  to 
eighth  intercostal  space,  and  from  this  it  gradually  fell  towards  spine. 
No  bulging  of  ribs,  and  portion  of  liver  below  margin  of  costal  arch 
very  firm  and  resisting,  not  at  all  tender,  and  perfectly  smooth.  The 
only  appreciable  inequality  was  a  transverse  furrow  situated  3^  in. 
above  umbilicus,  and  apparently  due  to  pressure  of  some  article  of 
clothing.  Lower  margin  of  liver  considerably  depressed  when  patient 
took  a  long  breath,  so  that  surface  of  organ  was  probably  not  adherent, 
or  only  slightly  so.  Dimensions  of  spleen  likewise  increased  (see 
fig.  10)  ;  it  did  not  project  beyond  the  margin  of  costal  arch,  but 
dimensions  of  dulness  were — vertically,  5^  in.,  and  transversely,  6^  in., 
instead  of  2  in.  vertically  and  4  in.  transversely,  as  in  normal  state. 
No  evidence  of  ascites  or  of  anasarca.  Appetite  bad  ;  tongue  coated 
with  a  white  fur,  and  for  some  weeks  after  admission  a  tendency  to 
vomiting  and  diarrhoea,  there  being  three  or  four  relaxed  motions 
daily.  Patient  did  not  complain  of  pain  in  abdomen,  except  of  occa- 
sional transient  attacks,  which  appeared  to  be  due  to  flatulence.  Chief 
complaint  was  of  weakness  in  limbs. 

Blood  and  urine  were  carefully  examined.  Blood  was  found  to 
contain  a  slight  but  decided  increase  in  proportion  of  white  corpuscles, 
while  many  of  the  red  corpuscles  were  of  irregular  outline  and  had  a 
tendency  to  tail.  Quantity  of  urine  voided  daily  was  ascertained  for 
several  weeks,  and  was  always  considerably  above  healthy  standard  ; 
average  quantity  was  from  three  to  four  pints,  and  occasionally  there 
was  more  than  four  pints.  Specific  gravity  varied  from  1010  to  1015  ; 
urine  always  contained  much  albumen,  but  it  was  perfectly  clear,  of 
an  amber  colour,  and  without  any  palpable  deposit.  Microscopic  ex- 
amination for  casts  for  the  most  part  yielded  negative  results  ;  on  one 
occasion  a  few  small  hyaline  casts  were  detected. 

For  first  five  days  after  patient's  admissitm  there  was  slight  febrile 
disturbance.  Pulse  ranged  from  110  to  120  ;  temperature  rose  to 
102°*4 ;  moist  and  dry  bronchial  rales  could  be  heard  over  back  of 
both  lungs.  Patient  had  also  sleepless  niglits,  but  without  any  rigors 
or  per.spirations.  After  this  pulse  and  temperature  were  normal,  and 
patient  slept  well ;  but  a  little  coarse  crepitus  could  generally  be  heard 
at  bases  of  lungs.     No  evidence  of  heart  disease. 

The  treatment  up  to  March  13,  1867,  consisted  in  mineral  acids, 
bitter  tonics,  and  a  generous  diet.      At  first,  sulphuric  acid  and  small 


lECT.  11,  TVAXT   LIVER.  43 

doses  of  laudanum  were  prescribed,  with  the  object  of  checking 
diaiT-hoea.  On  Jan.  9,  nitric  acid  was  substituted  for  the  sulphuric, 
and  was  given  with  small  doses  of  laudanum  in  the  compound  infusion 
of  gentian.  On  Feb.  8  opium  was  omitted,  and  a  grain  of  quinine 
substituted  for  the  compound  infusion  of  gentian.  The  diarrhoea, 
which  had  quite  ceased,  at  once  returned,  but  was  again  held  in 
check  by  the  restoration  of  laudauum  to  the  mixture  on  Feb.  13. 
Under  this  treatment  patient  steadily  and  greatly  improved.  He  had 
a  good  appetite,  and  was  much  stronger.  His  weight  on  admission 
was  only  7  st.  10^  lb. ;  but  on  March  13  he  had  gained  16  lb. 

Ajjril  3,  1867. — On  March  13  the  nitric  acid  was  discontinued, 
and  15  minims  of  compound  tincture  of  iodine  substituted.  After  this 
patient  continued  to  improve.  He  has  now  gained  20  lb.  since  ad- 
mission. There  has  been  no  diarrhoea,  and  quantity  of  urine  has 
diminished  almost  to  natural  standard.  No  material  change,  however, 
in  size  of  liver. 

Ajjril  29. — Patient  was  discharged  from  hospital  to-day,  greatly 
improved  in  strength  and  appearance,  No  diarrhoea,  and  urine  was 
of  normal  quantity,  with  only  -^-^  albumen.  Size  of  liver  also  greatly 
diminished,  as  will  be  obvious  from  following  dimensions.  In  median 
line,  6  in. ;  in  right  mammary  line,  7j  in.  ;  in  right  axillary,  6^  in. 
Vertical  splenic  dulness  only  4ji]i. 

The  circumstance  of  the  enlargement  of  the  liver,  in  this 
case,  commencing  in  the  tropics  with  acute  pain,  might  have 
been  thought  to  indicate  abscess  ;  but  opposed  to  abscess  were, 
the  duration  of  the  enlargement,  its  uniform  character,  its 
great  density,  the  absence  of  fluctuation,  and  the  fact  of  the 
patient  having  been  able  to  work  as  a  labourer  for  more  than 
twelve  months  prior  to  his  admission  into  the  Fever  Hospital. 
On  the  other  hand,  the  physical  characters  of  the  hepatic 
swelling,  the  enlargement  of  the  spleen,  the  excretion  of  a 
large  quantity  of  very  albuminous  urine  without  any  history 
of  dropsy,  the  tendency  to  diarrhoea,  the  condition  of  the 
blood,  and  the  syphilitic  history,  all  pointed  to  waxy  disease  as 
the  cause  of  the  enlargement.  As  regards  the  pain,  also,  it 
may  be  stated  that  Frerichs  records  a  case  of  waxy  disease  of 
the  liver,  in  which  '  the  first  symptom  was  persistent  cutting 
pains  in  the  side,  and  soon  his  strength  diminished  to  such  an 
extent  that  he  felt  it  necessary  to  give  up  his  work.  Almost 
at  the  same  time  he  observed  a  swelling  in  the  right  hypo- 
chondrium  and  epigastrium.'  The  cause  of  the  pain  was  no 
doubt  an  intercurrent  attack  of  peri-hepatitis,  as  was  observed 
after  death  in  Case  XI. 


44  ENLAEGEMENTS    OF   THE    LIVEK.  lect.  ii. 

Case  XI. — Constitutional  Syphilis,  followed  by  Waxy  Liver,  Spleen,  and 
Kidneys — No  Albuminuria — I'tri-liepatitis. 

Thomas   S ,  aged  23,   a  gardener,  adm.  into   Middlesex   Hosp. 

March  4,  1868.  At  beginning  of  18GG  he  had  conti'acted  syphilis, 
and  from  Aug.  2  to  Dec.  2,  1867,  he  had  been  a  patient  under  my 
care,  suffering  from  ulcerated  throat,  rupia,  and  periostitis  of  many  of 
his  bones,  -svith  attacks  of  pyrexia.  Liver  then  was  not  enlarged.  He 
came  under  my  care  the  second  time  on  account  of  urgent  diarrhoea, 
Avhich  had  lasted  about  a  fortnight.  He  Avas  then  greatly  emaciated, 
and  had  periosteal  SAvellings  on  frontal  bone,  both  clavicles,  both  tibiae, 
bones  of  forearms,  &c.  Tongue  dry  and  brownish  ;  no  appetite  ;  much 
thirst;  occasional  vomiting;  pi'ofnse  watery  diarrhoea;  stools  very 
offensive.  Liver  much  enlarged,  measuring  8  in.  in  right  mammary 
line  ;  enlargement  imiform  ;  surface  smooth  and  hard,  and  for  two 
days,  but  not  before,  intensely  tender.  No  jaundice  ;  no  ascites  ;  no 
obvious  enlargement  of  spleen  ;  no  albuminuria ;  and  no  anasarca. 

The  diarrhoea  was  checked  by  a  mixture  containing  tannic  acid 
and  a  few  drops  of  laudanum,  but  from  time  to  time  it  returned.  The 
tongue  became  dry,  red,  and  fissured;  abscesses  formed  over  the  jaw 
and  in  the  hip  ;  on  the  night  of  March  15  he  had  a  severe  attack  of 
convulsions,  from  which  he  recovered,  but  on  morning  of  the  31st  he 
had  a  second  tit,  and  remained  unconscious  until  his  death,  eight 
honrs  after.  Urine  throughout  contained  no  albumen  ;  that  passed 
on  day  before  death  was  copious,  and  had  sp.  gr.  of  1007. 

Autopsy. — Liver  greatly  enlarged,  extending  down  to  umbilicus  ; 
its  whole  surface  covered  Avith  a  thin  film  of  recent  lymph,  which 
could  be  easily  scraped  off;  surface  smooth,  moulded  over  adjacent 
parts  ;  structure  extremely  dense,  and  presenting  the  typical  characters 
and  reaction  of  Avaxy  disease  ;  Aveight,  131  oz.  About  one  fluid  ounce 
of  amber-coloured  gelatinous  mucus  in  gall-bladder.  Spleen,  12^  oz., 
firm  and  Avaxy,  Avith  appearance  of  sago-grains  on  section.  Kidneys 
apj)arently  healthy,  but  distinct  '  amyloid  '  reaction  of  Malpighian 
bodies.  Mucous  membrane  of  intestine  from  jejunum  to  end  of  ileum 
presented  marked  '  amyloid  '  reaction  of  minute  vessels  in  villi  and 
elscAvhere.  Cranial  bones  greatly  thickened,  and  diploe  filled  Avith 
dense  bony  matter  ;  a  soi't  node  over  frontal  bone,  and  corresponding 
bony  surface  rough  and  bare.  Cerebral  arteries  had  their  coats 
thickened,  but  were  not  stained  by  iodine ;  about  one  ounce  of  fluid 
in  lateral  ventricles.  Base  of  right  lung  carnified  from  compression 
by  liver. 

Case  XII. — Disease  of  Nasal  Bones — Ozo'na  and  Epistaxis — Great 
Enlargement  of  Liver — A  Ibmninuria. 

Philip    A ,    aged   41,    labourer,    adm.   into    Middlesex    Hosp. 

Feb.  14,  1871.     He  stated  that  he  had  enjoyed  good  health  until  16 


LECT.  n.  WAXY    LIVER.  45 

rnontlis  before,  •when  he  began  to  have  an  offensive  discharge,  with 
frequent  bleeding  from  nose,  and  a  troublesome  cough.  The  quantity 
of  blood  lost  was  often  considerable,  and  it  would  form  large  coagula 
in  left  nostril,  which  he  would  pull  out.  He  became  thin  and  weak, 
and  had  to  give  up  work,  and  for  nine  months  he  had  been  an  inmate 
of  another  hospital.  He  had  never  suffered  from  night-sweats, 
diarrhoea,  or  dropsy,  but  for  two  years  he  had  been  in  habit  of  getting 
up  two  or  three  times  in  night  to  void  water.  He  denied  ever  having 
had  syphilis. 

On  admission,  patient  was  thin,  sallow,  and  anaemic,  but  there  was 
no  trace  of  jaundice  or  dropsy.  He  had  a  fetid  discharge  from 
nostrils,  and  left  nostril  was  narrowed  from  projection  into  it  of  what 
appeared  to  be  a  portion  of  left  nasal  bone,  quite  bare  and  slightly 
loose.  Over  abdomen  and  legs  were  a  good  many  small,  copper- 
coloured,  scaly  spots.  Abdomen  large  and  prominent,  girth  at 
umbilicus  being  31  in.  ;  the  prominence  entirely  due  to  an  uni- 
formly enlarged  liver,  the  rounded  lower  margin  of  which  could  be 
felt  two  inches  below  umbilicus,  and  the  hepatic  dulness  extending 
from  nipple  10^  in.  downwards.  Surface  of  liver  smooth,  hard, 
and  painless.  Splenic  dulness  covered  twice  the  normal  area,  but 
lower  edge  of  spleen  could  not  be  felt  projecting  beyond  ribs.  Urine, 
while  patient  was  in  hospital,  was  examined  almost  daily  ;  its  quantity 
was  increased  sometimes  to  97  oz.  ;  its  specific  gravity  varied  from 
1010  to  1015  ;  and  it  usually  contained  albumen,  sometimes  as  much 
as  -^  in  volume,  but  no  tube-casts.  Slight  flattening,  dulness,  and 
prolonged  expiration  below  right  clavicle.  Pulse  80-100 ;  heart  dis- 
placed upwards,  but  in  other  respects  normal.  Tongue  red  and 
rather  devoid  of  epithelium  ;  appetite  good ;  bowels  regular.  White 
corpuscles  of  blood  considerably  increased.  During  patient's  stay  in 
hospital,  temperature  in  evening  frequently  rose  two  or  more  degrees, 
and  once  it  was  as  high  as  102'5°  ;  he  frequently  complained  of  frontal 
headache  and  pains  in  limbs  ;  for  several  days  he  had  a  slight  attack 
of  diarrhoea ;  and  on  April  11  he  had  a  sudden  and  rather  alarming 
attack  of  acute  cedema  of  the  glottis. 

The  treatment  consisted  in  mineral  acids  and  the  pemitrate  of  iron, 
"while  nostrils  were  washed  out  daily  with  solutions  of  Condy's  fluid, 
or  sulphurous  acid.  When  the  frontal  headache  was  most  severe  he 
took  iodide  of  potassium,  and  the  attacks  of  cedema  of  the  glottis 
yielded  speedily  to  leeches  and  hot  poultices  to  throat,  glycerine  of 
tannin  applied  to  rima  glottidis,  and  pernitrate  of  iron  internally. 
When  patient  left  hospital,  on  May  24,  he  was  considerably  better. 
The  liver  was  smaller,  but  hepatic  dulness  in  right  middle  lobe  still 
measured  9^  in. ;  the  albuminuria  had  for  some  time  disappeared  ; 
proportion  of  white  corpuscles  in  blood  had  diminished ;  evening 
temperature  was  normal,  and  discharge  from  nostrils  was  less. 


46  ENLARGEMENTS    OF   THE    LIVER.  lect.  ii. 

Case  XIII. — Si/p^iilitic   Necrosis    of  Lower  Jaw — Alhvmimiria — Diar- 
rhoea— Pleurisy  and  Pericarditis — Waxy  Liver  and  Kidneys. 

Jolm  R ,  aged  38,  adm.  under  my  care  into  Middlesex  Hosp. 

Dec.  17,  1867.  Six  or  seven  years  before  he  had  contracted  syphilis, 
and  four  years  before  he  had  been  con6ned  to  bed  for  three  months 
with  a  painful  affection  in  joints,  which  he  believed  to  have  been 
rheumatism,  and  ever  since  he  had  been  liable  to  pains  in  bones  and 
joints.  Twelve  months  before  he  had  been  a  patient  in  same  hospital 
with  albuminuria  and  slight  cedema  of  legs,  and  at  that  time  the 
alveolar  process  of  right  side  of  lower  jaw  had  exfoliated.  Ten  weeks 
before  admission,  he  had  been  seized  with  cough,  dyspnoea,  and  pain 
in  right  side  of  chest. 

On  admission,  patient  had  an  angemic,  chlorotic  countenance,  with 
slight  general  anasarca.  The  urine  contained  a  very  large  quantity  of 
albumen — about  one- half — but  no  tube-casts  ;  it  was  passed  in  con- 
siderable quantity,  and  had  a  specific  gravity  of  1015.  Absolute 
dulness  over  whole  of  right  lung,  with  all  the  signs  of  pleuritic  eflfu- 
sion.  Cardiac  dulness  also  increased,  but  could  not  be  isolated  from 
that  of  right  lung  ;  sounds  of  heart  feeble,  but  no  abnormal  murmur 
could  be  detected.  Pulse  9G.  Tongue  clean  and  red  ;  breath  ex- 
tremely offensive ;  no  appetite,  and  frequent  vomiting.  Hepatic 
dulness  extended  downwards  uniformly,  about  fwo  inches  below 
normal  boundary  ;  above,  it  could  not  be  well  defined  from  dulness 
over  right  lung.  The  portion  of  liver  projecting  below  right  ribs  was 
smooth  and  free  from  tenderness.  Splenic  dulness  not  increased. 
Patient  suffered  much  from  want  of  sleep. 

Treatment  proved  of  no  avail  in  relieving  patient's  condition.  On 
Jan.  2,  profuse  diarrhoea,  with  watery,  very  offensive  motions,  came 
on.  This  continued  until  patient's  death  occurred,  on  Jan.  7,  by 
exhaustion  rather  than  by  coma. 

On  examining  body,  there  Avas  great  thickening  with  firm 
adhesions  of  right  pleura  in  front ;  posteriorly,  right  lung  was 
separated  from  chest-wall  by  about  thirty  ounces  of  turbid  fluid. 
Right  lung  extremely  dense  from  fibroid  change.  Pericardium  con- 
tained about  twelve  ounces  of  turbid  scrum,  and  surface  of  heart  coated 
with  a  thick  rough  layer  of  rather  firmly  adherent  lymph.  Liver, 
spleen,  and  base  of  right  lung  all  firmly  adherent  to  diaphragm. 
Liver  weighed  66  oz.  ;  it  was  extremely  dense,  and  presented  the  naked 
eye  appearances  and  chemical  reaction  of  waxy  deposit.  Spleen  of 
natural  size  and  rather  soft.  Kidneys  of  about  normal  size ;  their 
surfaces  slightly  granular  ;  cortices  extremely  dense  and  pale,  and  the 
straight  vessels  and  Malpighian  bodies  exhibited  in  a  characteristic 
manner  the  so-called  '  amyloid  reaction.'  Mucous  membrane  of 
small  intestine  intensely  injected,  but  exhibited  no  'amyloid  reaction.' 

In  the  following  case  which  occurred  some  years  ago  in 


lECT.  II.  WAXY    LIVEE. 


47 


the  Middlesex  Hospital,  the  diagnosis  was  rendered  difficult  by 
the  irregular,  nodulated  lorm  of  the  enlarged  liver.  The  case 
was  under  the  care  of  Dr.  Greenhow,  and  is  recorded  in  the 
'  Pathological  Transactions,'  vol.  xvi.  p.  147. 


Case  XIV. — Waxy  Liver,  enlarged  and  nodulated,  simulating  Cancer. 

The  patient  was  a  baker,  33  years  of  age  at  time  of  bis  death,  on 
Oct.  12,  1864.  ISTo  cause  could  be  assigned  for  the  disease,  but  a  scar 
of  doubtful  nature  was  noticed  in  right  groin.  He  first  came  under 
observation  about  four  months  before  his  death,  and  althouo-h  liver 
was  then  about  as  large  as  when  he  died,  it  had  never  been  seat  of 
pain  or  discomfort,  and  indeed  patient  was  unaware  of  existence  of 
any  tumour  in  abdomen  until  it  was  discovered  at  the  hospital.  The 
tumour  extended  from  right  to  left  side,  so  as  to  occupy  both  hypo- 
ebondria.  Absolute  dulness  on  percussion  from  fourth  right  rib  to 
an  inch  above  level  of  umbilicus.  The  tumour  was  not  in  slio-htest 
degree  tender,  and  its  surface  was  perfectly  smooth.  A  smooth 
globular  prominence  in  epigastrium,  however,  simulated  somewhat  a 
deeply-seated  hydatid  tumour,  while  a  nodulated  border  and  ascites 
subsequently  gave  rise  to  suspicion  of  cancer.  Still,  the  absence  of 
pain  or  of  usual  phenomena  of  cancerous  cachexia  negatived  suppo- 
sition of  cancer  ;  while  the  density  of  epigastric  tumour,  the  enlarge- 
ment of  the  spleen,  and  the  condition  of  urine  were  in  favour  of  waxy 
disease  rather  than  of  hydatid. 

A  fortnight  before  patient  was  first  seen,  his  feet  had  beo-un  to 
swell,  and  the  anasarca  gradually  extended  up  to  thighs  and  scrotum. 
About  two  months  before  death  fluid  began  to  collect  in  peritoneum 
but  dropsy  never  invaded  arms  or  upper  part  of  body.  The  urine  was 
copious,  about  three  pints,  and  contained  much  albumen,  but  rarely 
any  casts.  At  no  time  was  there  jaundice.  Towards  the  last  patient 
became  greatly  emaciated,  and  he  finally  died  exhausted. 

Liver  weighed  1841  qz.,  and  was  in  an  advanced  stage  of  albu- 
minous or  waxy  disease,  yielding  a  most  characteristic  reaction  with 
iodine.  Spleen,  kidneys,  and  lymphatic  glands  in  portal  fissure  were 
also  greatly  enlarged,  and  had  undergone  a  similar  change.  Both 
lobes  of  liver  were  equally  enlarged,  but  they  were  prolonged  upwards 
and  backwards,  so  as  to  leave  a  fissure  five  inches  in  depth  at  posterior 
margin,  corresponding  to  the  attachment  of  suspensory  ligament. 
Anterior  border  was  much  thickened,  and  was  also  indented  by  two 
deep  fissures,  corresponding  to  the  notches  of  suspensory  ligament 
and  gall-bladder,  which  imparted  to  it  a  lobulated  character.  On 
upper  surface,  also,  corresponding  to  epigastrium,  there  was  a  semi- 
globular  elevation  three  inches  in  diameter.  Under  surface  was 
marked   by    deep    depressions,    corresponding   to    right   kidney   and 


48  ENLARGEMENTS    OF   THE    LIVEE.  lect.  ii. 

spleen.  Surface  of  liver  generally  smooth,  but  capsule  mucli  thickened, 
and  superiorly  adherent  to  diaphragm.  Stomach,  intestines,  and 
heart  normal. 


II.    THE  FATTT    LIVER. 

The  second  form  of  painless  enlarg-ement  of  the  liver  is 
that  -which  is  due  to  the  accumulation  of  oil,  or  '  the  fatty 
liver.'  This  form  of  hepatic  enlargement  has  the  following- 
clinical  characters  : — 

1.  The  enlargement  may  be  considerable,  but  is  rarely  so 
great  as  that  often  attained  by  the  waxy  liver.  It  is  not  often 
that  the  anterior  or  lower  border  reaches  down  beyond  the 
umbilicus,  or  even  so  far.  Occasionally,  however,  the  vertical 
hepatic  dulness  is  increased  out  of  proportion  to  the  actual 
amount  of  enlargement,  in  consequence  of  the  organ  being  so 
soft  and  flabby  that  it  bends  upon  itself  and  sinks  downwards, 
and  thus  the  anterior  margin  is  depressed  and  a  larger  portion 
of  the  organ  is  brought  into  apposition  with  the  abdominal 
parietes. 

2.  As  in  waxy  disease,  the  enlargement  is  tolerably  uni- 
form in  every  direction  and  there  are  no  circumscribed  bulg- 
ings,  so  that  the  natural  form  of  the  liver  is  but  little  altered. 
There  is  no  expansion  or  bulging  of  the  lower  ribs. 

3.  The  enlarged  liver  is  less  resisting  to  pressure,  and  is 
doughy  and  of  softer  consistence  than  in  the  waxy  disease.  When 
the  abdominal  parietes  are  thin,  the  soft,  doughy  consistence 
of  the  enlargement  may  be  readily  appreciated;  but  when 
the  parietes  are  thick  it  may  be  difficult  to  determine  its  phy- 
sical characters. 

4.  The  outer  surface  is  smooth,  and  the  lower  margin  even 
and  rounded,  except  where  there  is  some  more  important 
disease  such  as  cirrhosis,  in  conjunction  with  the  fatty  de- 
generation. 

5.  There  is  no  ascites  or  enlargement  of  the  superficial 
veins  of  the  abdomen.  A  large  accumulation  of  oil  in  the  liver 
interferes  with  the  circulation  so  far  as  to  lead  to  an  anaimic 
condition  of  the  liver  itself,  but  never  to  such  an  extent  as  to 
cause  ascites. 

G.  Even  in  extreme  cases  bile  continues  to  be  secreted,  and 
its  secretion  is  not  arrested  or  impeded.  Jaundice,  therefore, 
is  not  a  symptom  of  uncomplicated  fatty  liver. 

7.  The  same  remark  applies  to  pain.     Tatty  enlargement 


FATTY    LIVEE. 


49 


of  the  liver  is  painless  from  first  to  last.  The  organ  can  be  freelj 
manipulated  with  impunity,  although  in  extreme  cases  the 
patient  may  complain  of  a  feeling  of  weight  or  distension  in 
the  abdomen,  increased  by  turning  on  the  left  side. 

8.  From  the  absence  of  symptoms,  few  opportunities  are 
afforded  of  watching  the  growth  of  fatty  enlargement  of  the 
liver,  but  this  is  usually  slow  and  imperceptible. 

9.  The  constitutional  symptoms  of  fatty  liver  are  few  and 
not  characteristic,  and  those  which  have  been  noted  are  often 
due  for  the  most  part  to  co-existing  fatty  degeneration  of 
other  organs,  and  more  especially  of  the  heart.  General  de- 
bility, great  ansemia,  and  want  of  tone  in  the  nervous  and 
vascular  systems  are  amongst  the  most  prominent  symptoms. 
The  patient  suffers  from  languor,  is  easily  tired,  and  bears 
depletion  or  the  inroads  of  acute  disease  badly.  The  late  Dr. 
Addison  described  a  condition  of  the  integuments  which  he 
believed  to  be  pathognomonic  of  fatty  degeneration  of  the 
liver.  '  To  the  eye,'  he  says,  ^  the  skin  presents  a  bloodless, 
almost  semi-transparent,  and  waxy  appearance.  When  this  is 
associated  with  mere  pallor  it  is  not  very  unlike  fine  polished 
ivory,  but  when  combined  with  a  more  sallow  tinge,  as  is  now 
and  then  the  case,  it  more  resembles  a  common  wax  model. 
To  the  touch,  the  general  integuments,  for  the  most  part,  feel 
smooth,  loose,  and  often  flabby ;  whilst  in  some  well-marked 
cases  all  its  natural  asperities  would  appear  to  be  obliterated, 
and  it  becomes  so  exquisitely  smooth  and  soft  as  to  convey  a 
sensation  resembling  that  experienced  on  handling  a  piece  of 
the  softest  satin.'  ^  These  appearances  are  chiefly  met  with 
in  females,  and  although  they  are  far  from  being  invariably 
present,  yet  in  most  cases  of  fatty  liver  the  countenance  and 
general  integuments  are  more  or  less  pasty  and  anaemic,  and 
sometimes  the  skin  appears  greasy  from  increased  action  of 
the  sebaceous  follicles.  Patients  with  fatty  liver  also  suffer 
often  from  dyspeptic  symptoms,  such  as  flatulence,  hypochon- 
driasis, irregular  action  of  the  bowels — usually  constipation, 
but  occasionally  profuse  diarrhoea  from  slight  causes. 

10.  Enlargement  of  the  spleen  is  rarely  present.  The 
portal  circulation  is  not  obstructed  to  such  an  extent  as  to 
lead  to  enlargement iof  this  organ  from  stasis  of  blood ;  and 
the  spleen  is  not  liable,  as  in  waxy  disease,  to  a  deposit  of  the 
same  material  as  that  which  causes  the  liver  to  enlarge. 

1  Guy's  Hospital  Eeports,  First  Series,  vol.  i.  1836,  p.  479, 
E 


50  ENLAEGEMENTS    OP   THE    LIVER.  rECT.  ir. 

There  are,  however,  certain  other  organs  which  are  apt  to 
undergo  fatty  degeneration  as  well  as  the  liver,  and  the  disease 
in  each  of  these  organs  has  symptoms  of  its  own,  which,  when 
present,  will  throw  light  on  the  nature  of  the  hepatic  en- 
largement.    Thus— 

11.  When  there  is  concurrent  fatty  degeneration  of  the 
heart,  in  addition  to  the  signs  already  enumerated,  there  are 
often — 

a.  A  very  feeble,  or  even  inappreciable,  cardiac  impulse. 

6.  Very  faint,  or  even  inaudible,  cardiac  sounds,  the  first 
sound  in  particular  being  short  and  feeble. 

c.  A  very  slow,  or  a  quick,  feeble,  and  irregular  radial  pulse. 

d.  Attacks  of  vertigo,  syncope,  or  pseudo-apoplexy. 

e.  Dyspnoea  or  sternal  pain  on  slight  exertion,  and  a  feeling 
of  sinking  at  the  epigastrium. 

•12.  When  there  is  concurrent  fatty  degeneration  of  the 
kidneys,  in  addition  to  the  signs  already  enumerated,  there 
will  usually  be — 

a.  Urine  below  the  normal  standard  in  quantity,  oftener 
turbid  than  clear,  containing  much  albumen,  and  depositing 
numerous  oil-casts. 

6.  A  tendency  to  general  anasarca. 

c.  Extreme  pallor  and  pastiness  of  countenance. 

13.  As  in  waxy  disease  of  the  liver,  the  diagnosis  will  often 
be  materially  aided  by  attending  to  the  circumstances  under 
which  the  enlargement  occurs.  Many  different  conditions  of 
the  system  may  give  rise  to  fatty  enlargement  of  the  liver, 
but  most  of  them  may  be  referred  to  one  of  the  following 
heads : — 

a.  Large  accumulations  of  fat  beneath  the  skin  throughout 
the  body,  in  persons  who  for  the  most  part  are  large  feeders 
and  lead  indolent  lives.  It  is  in  this  condition  that  the  heart 
is  most  likely  to  participate  in  the  fatty  change,  and  that  you 
will  expect  to  discover  the  symptoms  of  fatty  heart  already 
referred  to.  It  is  persons  in  this  state  who  are  most  prone  to 
die  of  rupture  of  the  heart.  In  the  '  Pathological  Transac- 
tions '  you  will  find  several  cases  recorded  in  which  patients 
died  of  rupture  of  the  heart,  and  where  not  only  was  the  heart 
found  in  a  state  of  fatty  degeneration,  but  the  liver  was  enor- 
mously enlarged  from  fatty  deposit,  and  there  was  a  large 
accumulation  of  fat  throughout  the  body.' 

'  See  particiiliii'ly  case  by  Dr.  Quain,  vol.  iii.  p.  2G2  ;  and  case  by  Mr.  Pollock, 
vol.  XV.  p.  84. 


XECT.  11.  TATTY   LIVEE.  51 

h.  Alcoholism. — Persons  ■who  drink  immoderately  of  ardent 
spirits,  particularly  if  tliey  take  little  exercise,  are  very  subject 
to  fatty  liver.  Of  thirteen  persons  who  died  of  delirium 
tremens,  Frerichs  found  the  liver  very  fatty  in  six.  Of  two 
fatal  cases  of  delirium  tremens  in  which  an  autopsy  was  made 
by  me  in  the  Middlesex  Hospital  some  years  ago,  there  was 
considerable  fatty  enlargement  of  the  liver  in  both :  in  one  the 
organ  weighed  eighty-three  ounces;  in  the  other  ninety-six 
ounces.  It  is  under  these  circumstances  that  the  kidneys  often 
participate  in  the  fatty  degeneration  ;  the  quantity  of  fat  also 
which  some  of  these  patients  accumulate,  notwithstanding  the 
small  amount  of  solid  food  which  they  consume,  is  remarkable. 
When  the  practice  is  persisted  in,  the  fatty  liver  is  apt  to  be- 
come complicated  with  cirrhosis. 

c.  Phthisis. — The  great  frequency  of  fatty  enlargement  of 
the  liver  in  persons  suffering  from  pulmonary  consumption  has 
been  already  referred  to  under  the  head  of  the  waxy  liver 
(p.  36).  In  consumptive  females  it  is  much  more  common 
than  in  males.  In  this  disease,  it  is  not  a  little  remarkable 
that,  while  fat  disappears  rapidly  from  almost  every  tissue  in 
the  body,  it  should  accumulate  in  such  large  quantities  in  the 
liver. 

d.  Other  wasting  diseases  besides  phthisis — such,  for  in- 
stance, as  cancer,^  simple  ulcer  of  the  stomach,^  and  chronic 
dysentery^ — are  likewise  often  attended  by  fatty  enlargement 
of  the  liver. 

It  appears,  then,  that  fatty  liver  is  met  with  under  two 
opposite  conditions  :  one,  in  which  there  is  an  increased  supply 
of  material  capable  of  being  converted  into  oil,  and  where  fat 
often  accumulates  in  all  the  tissues  of  the  body ;  the  other,  in 
which  there  is  a  rapid  absorption  of  fat  from  all  the  tissues,, 
with  consequent  emaciation.  Its  mode  of  production  in  the 
former  case  is  sufficiently  obvious  ;  in  the  latter,  the  blood 
becomes  loaded  with  oily  matters  derived  from  the  jDatient's  own 
tissues,  and  this  oily  matter  is  separated  from  the  blood  in  its 
passage  through  the  liver.  The  impaired  absorption  of  oxygen 
in  phthisis,  interfering  with  the  proper  metamorphosis  of  the 

^  See  case  of  cancer  of  the  larynx,  by  Mr.  C.  Heath,  Pathological  Transactions, 
vol.  xiii.  p.  28  ;  and  case  of  extensive  cancerous  ulceration  of  groin,  by  Dr.  Budd, 
Diseases  of  Liver,  p.  299. 

2  Case  by  Mr.  E.  Eobiuson,  Path.  Trans,  vol.  iv.  p.  133  ;  and  by  Sir  H.  Thompson, 
id.  vol.  vi.  p.  186. 

^  Case  by  Dr.  Bright,  in  Hospital  Eeports,  vol.  i.  p.  117. 

B  2 


52  EKLAEGEMENTS    OF   THE    LIVER.  i.ect.  it, 

oil,  accounts  for  fatty  liver  being  more  common  in  pulmonary 
than  in  other  -wasting  diseases ;  and  the  greater  frequency  of 
fatty  liver  in  women  may  be  accounted  for  by  their  having  in 
general  a  larger  quantity,  than  men,  of  fat  to  be  absorbed. 

Treatment. — It  is  not  often  that  fatty  enlargement  of  the 
liver  causes  such  a  derangement  of  functions  as  in  itself  to  call 
for  treatment.  As  a  rule,  treatment  must  be  directed  against 
the  conditions  in  -which  the  enlargement  in  question  is  known 
to  occur. 

1.  When  the  disease  is  developed  in  persons  who  are  large 
feeders  and  of  indolent  habits,  the  fat  will  usually  disappear 
from  the  liver,  as  well  as  from  the  rest  of  the  body,  on  the 
individual  adopting  an  opposite  mode  of  life.  He  must  rise 
early  and  take  active  exercise  in  the  open  air,  and  live  princi- 
pally on  lean  meat,  fish,  bread,  and  green  vegetables,  with  light 
claret,  hock,  or  plain  water  to  drink,  and  avoid  butter,  fat,  oil, 
fermented  drinks,  strong  wines,  and  all  substances  rich  in 
starch  or  sugar.  Under  such  a  regimen,  the  fat  will  not  only 
disappear,  but  the  nutrition  of  the  muscles  will  be  improved, 
and  the  patient's  strength  increased.  In  cases,  however, 
where  there  is  reason  to  suspect  the  existence  of  fatty  degene- 
ration of  the  muscular  tissue  of  the  heart,  the  change  of  regi- 
men here  recommended  must  not  be  too  sudden,  and  its  effects 
must  be  carefully  watched,  while  caution  must  be  exercised  in 
withdrawing  the  accustomed  allowance  of  alcoholic  stimulant. 

2.  When  fatty  liver  is  the  result  of  alcoholism,  a  simple 
withdrawal  of  the  cause  will  usually  be  sufficient  to  effect  a 
diminution  in  the  size  of  the  liver. 

o.  Alkalies,  alkaline  carbonates,  or  compounds  of  the 
alkalies  with  the  vegetable  acids,  in  combination  with  some 
ve""etable  bitter,  such  as  taraxacum  or  gentian,  have  generally 
been  found  useful  for  correcting  the  digestive  derangements 
resulting  from  fatty  liver ;  and  if  the  bowels  be  constipated, 
recourse  may  also  be  had  to  occasional  doses  of  the  compound 
rhubarb,  or  colocynth  pills  of  the  Pharmacopeia,  in  combuia- 
tion  with  blue  pill  and  extract  of  henbane,  or  to  a  dinner  pill 
containing  the  watery  extract  of  aloes  and  nux  vomica. 
Eating  large  quantities  of  common  salt  with  the  food  has 
sometimes  appeared  useful;  and,  when  circumstances  permit, 
it  may  be  advisable  to  recommend  a  trial  of  the  alkaline  or 
saline  mineral  waters  of  Carlsbad,  Marienbad,  Kissingen,  Ems, 
or  Vichy. 


lECT.  II.  SIMPLE    HTPEETEOPHT.  53 

4.  The  preparations  of  iron  are  often  of  great  service  in 
cases  where  there  is  marked  ansemia,  and  those  which  are  best 
suited  are  the  ferrnm  redactum,  the  ferri  et  quinise  citras,  the 
ferri  et  ammonise  citras,  and  the  mistura  ferri  composita. 
Thej  are  often  advantageously  combined  with  alkalies.  The 
chalybeate  mineral  waters  of  Tunbridge  or  Moffat,  or  of  Spa, 
Pyrmont,  or  Schwalbach  on  the  Continent,  are  useful  for  the 
same  object. 

5.  Lastly,  when  the  disease  appears  in  the  course  of 
phthisis,  it  rarely  calls  for  any  special  treatment,  but  its  pre- 
sence is  a  contra-indication  to  the  use  of  cod-liver  oil,  or  other 
oleaginous  remedies. 

In  the  following  case,  I  had  several  opportunities  of  demon- 
strating to  you  in  the  wards  the  clinical  characters  of  the  fatty 
liver.  The  absence  of  albuminuria  or  of  enlargement  of  the 
spleen  made  it  improbable  that  the  enlargement  was  due  to 
waxy  deposit. 

Case  XV. — Acute  FMMsis — Fatty  Liver.. 

Charles  C ,  aged  57,  was  adm.  into  Middlesex  Hosp.  under  my 

care,  June  11,  1867.  He  had  enjoyed  good  health  until  about  two 
months  before,  when  he  began  to  suffer  from  frequent  cough,  emacia- 
tion, and  night-sweats,  and  subsequently  from  diarrhoea.  On  admis- 
sion he  was  very  thin  and  prostrate ;  frequent  cough,  with  purulent 
expectoration ;  marked  dulness  for  several  inches  below  right  clavicle, 
and  coarse  moist  rales  audible  over  whole  of  both  lungs.  Bowels  very 
relaxed.  Liver  much  enlarged  ;  hepatic  dulness  in  right  mammary 
line  measuring  7  in.,  and  reaching  fully  3  in.  below  margin  of  ribs. 
Enlargement  was  uniform  ;  its  outer  surface  smooth,  but  much  softer 
and  less  resisting  than  that  of  waxy  liver,  and  it  was  devoid  of  all  pain 
or  tenderness.  No  jaundice,  albuminuriaj  or  enlargement  of  spleen. 
The  patient  rapidly  sank,  and  died  on  June  16. 

On  examination  of  body,  both  lungs  infiltrated  throughout  with 
yellow  tubercle,  breaking  down  at  apices  into  small  caYities.  At 
right  apex  pulmonary  tissue  had  entirely  disappeared.  I^umerous 
small  ulcers,  without  tubercular  deposit  at  edges  or  base  in  large 
intestine.  Kidneys  and  spleen  healthy.  Liver  much  enlarged,  weighed 
78  ounces,  smooth,  pale  yellow,  opaque,  a;nd  extremely  friable  ;  the 
secreting  cells  throughout  loaded  with  oil. 

III.    SIMPLE    HTPEETEOPHT. 

By  '  simple  hypertrophy  '  is  understood  an  enlargement  of 
the  liver,  due  to  an  increased  size  of  the  lobules  and  an  in- 


54  ENLARGEMENTS   OP  THE   LIVEK.  i-ect.  ii. 

creased  size  or  number  of  secreting  cells,  without  any  altera- 
tion of  structure.  The  enlargement  of  the  liver  is  uniform  and 
rarely  great ;  and,  as  might  be  expected,  it  is  not  attended 
by  any  prominent  symptom.  The  condition  is  comparatively 
rare,  and  has  still  to  be  studied.  It  has  chiefly  been  observed 
in: 

a.  Leukaemia;  and  in 

h.  Exceptional  cases  of  saccharine  diabetes.^ 
Hence,  when  the  liver  is  found  enlarged  in  either  of  these 
maladies  without  any  obvious  derangement  of  its  functions, 
simple  hypertrophy  may  be  suspected.  It  has  been  suggested 
that  the  enlargement  of  the  liver  arising  from  protracted 
residence  in  hot  climates  may  be  of  this  na.ture  ;  but  in  most 
cases  this  is  due  to  hypersemia  or  to  waxy  disease  (see  Lecture 
IV.). 

'  See  Frericlis'  Diseases  of  Liver,  Syd.  Soc.  Transl.  vol.  ii.  p.  210.  According  to 
Budd,  the  liver  in  diabetes  is  often  unusually  small,  and  the  lobules  shrunken,  from 
the  quantity  of  oil  being  below  the  normal  ttiindard  (Diseases  of  Liver,  3rd  ed.  p.  310). 
In  many  cases  after  death  from  diabetes  the  liver  presents  nothing  abnonnal. 


55 


LECTUEE   III. 

ENLARGEMENTS  OF  THE  LIVER. 
IV.    HYDATID    TUMOUR. 

The  fourth  form  of  painless  enlargement  of  tlie  liver  is  that 
which  is  due  to  the  presence  of  hydatid  tumour.  Although  the 
disease  is  less  common  in  this  than  in  some  other  countries,^ 
I  have  frequently  had  opportunities  of  pointing  out  to  you  its 
clinical  characters,  which  are  mainly  the  following  : — 

1.  The  enlargement  may  be  very  great,  so  as  to  fill  the 
greater  part  of  the  abdominal  cavity,  or  reach  upwards  to  near 
the  clavicle,  but  in  its  earlier  stages  the  hydatid  may  form  a 
globular  tumour  at  one  part  of  the  liver,  not  larger  than  an 
orange ;  or  from  its  situation  and  size  it  may  altogether  elude 
observation. 

2.  Unlike  any  of  the  enlargements  already  considered,  it 
is  not  uniform  in  every  direction,  but  usually  it  follows  one 
direction  in  particular ;  so  that  the  natural  form  of  the  liver  is 
greatly  altered  (figs.  12  and  13).  If  it  grow  upwards,  the 
natural  arched  outline  of  the  upper  boundary  of  hepatic  dulness 
will  be  exaggerated ;  if  it  grow  downwards,  the  lower  boundary 

'  Out  of  2,100  post-mortem  examinations  recorded  at  tlie  Middlesex  Hospital  be- 
tween April  19,  1853,  and  August  25,  1863,  hydatids  were  found  in  only  13,  or  once 
in  161  cases;  and  in  only  7  of  the  13  cases,  or  once  in  300  cases,  were  they  the  cause 
of  death.  But  in  Iceland,  Eschricht  has  calculated  that  about  one-sixtli  of  the  entire 
population  are  afflicted  with  hj'datids :  and  according  to  Hjaltelin,  they  are  found  in 
nearly  one-fifth  of  all  adult  dead  bodies.  {Brit.  Med,  Journ.  Aug.  14,  1869.)  In 
Australian  hospitals,  hydatids  are  the  cause  of  one  in  every  139  deaths.  (Macgillivray, 
Aicstralian  Med.  Journ.  March  1867.)  On  the  other  hand,  hydatids  are  much  rarer 
in  Scotland  than  in  England.  Dr.  Scott  Orr  has  searched  the  records  of  the  Glasgow 
Koyal  Infirmary  from  the  earliest  periods,  but  has  only  found  three  cases,  one  in  the 
mamma,  and  two  in  the  liver,  {Glasgow  Med.  Journ.  Jan.  1876.)  Dr.  Grairdner 
also  states  that  among  many  thousand  dissections,  which  he  had  either  performed 
or  seen  performed,  during  his  connection  with  the  Edinburgh  Royal  Infirmary,  in  only 
one  instance  had  a  hydatid  been  found  in  any  part  of  the  body,  and  that  was  in  the 
upper  part  of  the  right  lung.  The  patient  came  apparently  from  Newcastle.  {Clinical 
Medichie,  p.  431.)  Can  this  immunity  be  due  to  the  non-importation  of  foreign  sheep 
into  Scotland  ? 


$6  ENLARGEMENTS    OF    THE    LIVEE.  i-ect.  hi. 

of  hepatic  dulness  will  be  found  to  be  natural  at  some  places, 
wliile  at  others  there  is  an  abrupt  protuberance  or  tumour  (see 
fig.  12).  Not  unfrequently  it  takes  a  lateral  direction,  and 
causes  more  or  less  bulirino-  of  the  ribs ;  and  then  the  disease  is 
apt  to  be  mistaken  for  empyema,  which  is  distinguished  bj  the 
characters  already  enumerated  (see  page  12).  It  is  the  right 
lobe  of  the  liver  from  which  the  tumour  commonly  grows. 

3.  It  is  neither  dense  nor  doughy,  but  elastic,  or  even 
fluctuating.  If  the  hydatid  be  deeply  seated,  with  much  he- 
patic tissue  sej)arating  it  from  the  outer  surface,  the  tumour 
will  be  onl}'-  elastic  ;  but  if  it  approach  near  to  the  surface  there 
will  be  distinct  fluctuation,  with  a  thrill  as  from  fluid,  on  pal- 
pation. Occasionally  there  is  the  sign  known  as  '  hydatid 
vibration.''  This  is  a  peculiar  trembling  sensation,  experienced 
when  three  fingers  of  the  left  hand  are  laid  flat  on  the  tumour, 
and  the  back  of  the  left  middle  finger  is  struck  abruptly  with 
the  point  of  the  middle  finger  of  the  right  hand.  This  sign  is 
not  due,  as  is  commonly  stated,  to  the  secondary  cysts  in  the 
interior  striking  the  wall  of  the  parent ;  it  may  be  detected 
in  barren  hydatids,^  and  it  is  not  peculiar  to  hydatid  tumours. 
It  is  elicited  when  any  large  cyst,  with  thin  tense  walls  and 
watery  contents,  is  treated  in  the  manner  above  described. 
But,  inasmuch  as  the  only  tumours  of  the  liver  answering  to 
these  characters  are  hydatids,  the  sign  referred  to,  when  pre- 
sent, is  of  considerable  value  in  the  diagnosis  of  hydatids  in  the 
liver.  Unfortunately,  in  a  large  ^jroportion — probably  the 
majority — of  cases  of  hydatid  tumours  of  the  liver,  it  is  alto- 
gether wanting. 

4.  The  surface  of  the  tumour  is  smooth,  and  free  from 
irregularities  of  every  sort.  In  rare  cases,  when  there  are 
several  distinct  cysts  projecting  from  the  surface  of  the  liver, 
this  organ  may  appear  through  the  abdominal  parietes  to  have 
somewhat  of  a  lobulated  character,  which  may  occasion  con- 
siderable embarrassment  in  diagnosis.  The  possibility  of  this 
source  of  fallacy  must  be  kept  in  view. 

5.  Ascites,  oedema  of  the  lower  extremities,  enlargement  of 
the  superficial  veins  of  the  abdomen,  and  haemorrhoids  are  not 
distinguishing  characters  of  hydatid  enlargement  of  the  liver. 
Their  occurrence  in  rare  cases  must  be  regarded  as  in  some 
measure  accidental,  and  duo  to  comijression  by  the  tumour  of 
the  trmik  of  the  portal  vein,  or  of  the  inferior  vena  cava,  or  of  the 

'  Sco  also  Troussciiu's  Clin.  Lect.  Syd.  Soc.  Ed.  iv.  27.5. 


XECT.  III.  HYDATID    TUMOUR.  5/^ 

iliac  veins.  Care  must  be  taken  not  to  mistake  for  ascites  an 
enormous  hydatid  tumour  projecting*  down  from  tlie  liver  and 
filling  tlie  fore-part  of  the  abdominal  cavity.  Tliis  is  dis- 
tinguished by  a  history  of  growth  from  above  downwards,  and 
by  the  portions  of  the  abdomen  yielding  tympanitic  percussion 
not  being  the  most  elevated  in  any  position  of  the  patient.  For 
instance,  when  the  patient  lies  on  his  back,  there  may  be  dul- 
ness  on  percussion  and  unmistakable  evidence  of  fluid  in  the 
most  elevated  part  of  the  abdomen,  while  in  both  flanks  the 
percussion  is  tympanitic  (see  Case  XXXYIII.).  When  hydatid 
tumour  of  the  liver  co-exists  with  ascites,  and  no  opportunity 
has  been  afforded  of  examining  the  patient  prior  to  the  ascites, 
the  diagnosis  will  be  extremely  difficult,  if  not  impossible. 

6.  Enlargement  of  the  spleen  is  not  a  common  consequence  of 
hydatid  enlargement  of  the  liver,  but  may  occur  under  condi- 
tions similar  to  those  which  occasion  ascites.  In  very  rare 
cases,  the  spleen  may  be  enlarged  from  the  presence  of  secon- 
dnYj  hydatid  tumours. 

7.  Jaundice  is  also  an  exceptional,  and,  so  to  speak,  acci- 
dental symptom  of  hydatid  enlargement  of  the  liver.  When 
present,  it  is  due  to  pressure  by  the  tumour  on  the  common 
bile-duct,  which  is  thereby  narrowed  or  even  obliterated,  to 
catarrh  of  the  bile-ducts,  or  to  the  bursting  of  the  tumour  into 
the  ducts,  which  become  obstructed  by  its  contents.  I  show 
you  here  a  specimen  taken  from  the  body  of  a  gentleman  under 
my  care,  in  whom  jaundice  was  due  to  the  last  of  these  causes 
(Case  XXXIV.),  and  you  have  had  opportunities  of  studying  the 
symptoms  in  similar  cases,  which  have  proved  fatal  in  the 
hospital  (Cases  XXXI  to  XXXIII.). 

8.  Enlargement  of  the  liver  from  hydatid  tumour  rarely 
interferes  with  the  functions  of  the  kidneys,  and  hence  we  do 
not  meet  with  those  alterations  in  the  urine  so  common  in 
waxy,  and  of  frequent  occurrence  in  fatty,  enlargements.  In. 
rare  cases,  however,  the  kidneys  also  may  be  the  seat  of  hyda- 
tids, or  pyelitis  may  be  induced  by  the  pressure  of  a  large 
hydatid  tumour  of  the  liver  on  the  ureter.  Under  these  circum- 
stances the  urine  may  contain  large  quantities  of  pus,  as  hap- 
pened in  a  patient  who  was  under  my  care  in  this  hospital  a. 
few  years  ago,  and  the  particulars  of  whose  case  I  shall  narrate 
to  you  presently  (Case  XLII.).  Occasionally  the  urine  contains 
albumen,  apparently  from  pressure  on  the  renal  vein,  as  it  dis- 
appears after  the  cyst  has  been  tapped. 


58  ENLAKGEMENTS    OF    THE    LIVEB..  lkct.  iir. 

9.  The  growth  of  a  hydatid  tumour  is  slow  and  impercep- 
tible, and,  when  the  tumour  is  large,  it  has  usually  existed  for 
years  before  the  patient  has  recourse  to  medical  advice.  Dr. 
Eudd  mentions  the  case  of  a  lady  who  died  at  the  age  of  73, 
and  in  whose  body  two  hydatid  tumours  of  the  liver  were 
found,  which  there  Avas  reason  to  believe  had  existed  since  she 
was  eight  years  old.^ 

10.  The  latent  character  of  hydatid  enlargement  of  the 
liver  is  one  of  its  chief  characteristics.  It  often  attains  a  great 
size  without  causing  any  pain  or  uneasiness,  and  often  indeed 
without  the  patient  being  aware  of  its  existence,^  and  unless 
the  sac  be  inflamed  on  its  inner  or  outer  surface,  the  tumour 
can  usually  be  manipulated  freely  without  causing  tenderness. 
The  first  local  indications  of  its  presence  are  those  resulting 
from  pressure  on  adjoining  parts,  a  feeling  of  weight  or  disten- 
sion, of  dragging  pains,  or  of  embarrassment  of  the  breathing. 
Then,  and  not  till  then,  it  may  become  the  seat  of  occasional 
attacks  of  acute  pain  and  tenderness,  in  consequence  of  inflam- 
mation of  the  superimposed  peritoneum.  But  now  and  then,  a 
comparatively  small  tumour  causes  pain,  by  projecting  in  a 
direction  where  there  is  little  space  for  its  growth,  or  by  com- 
pressing some  nerve  (Case  XXI,). 

11.  There  may,  in  like  manner,  be  an  absence  of  all  con- 
stitutional symptoms.  Even  when  of  large  size,  the  tumour 
often  does  not  interfere  Avith  the  functions  of  the  liver.  There 
is  no  pyrexia  or  impairment  of  the  general  health,  and  the 
chief  symptoms  are  those  due  to  pressure  on  adjoining  organs, 
and  interference  with  their  functions.  Some  years  ago  a 
patient  came  to  me  complaining  of  cough  and  shortness  of 
breath,  and  fearing  that  she  was  consumptive.  On  examining 
the  chest,  I  found  an  enormous  hydatid  tumour  of  the  liver 
compressing  the  right  lung,  and  causing  great  bulging  outwards 
of  the  ribs,  as  well  as  a  prominent  tumour  in  the  abdomen. 
The  patient  had  suffered  nothing  except  the  cough  and  dys- 
pnoea, and  was  not  aware  of  the  existence  of  any  tumour  (Case 
XLII.).  Instances  also  are  not  uncommon  of  patients  who 
have  died  from  acute  inflammation  excited  by  the  bursting 
of  a  larg(;  hydatid  tumour  of  the  liver,  Avho,  previous  to  the 

'  Disejises  of  Liver,  Srd  cd.  p.  433. 

*  Of  17  .specimens  of  liydatid  of  tlio  liver  in  llio  Berlin  Patliologicnl  Institute,  13 
liad  given  rise  to  uo  byniptonis.  (/elkr,  in  Zieins.suu's  Cyclop,  of  Med.  vol.  iii.  p. 
693.) 


LECT.  111.  HYDATID    TUMOUE.  59 

attack  of  fatal  inflammation,  liave  been  tliouglit  to  be  in  perfect 
Jiealtli  (Case  XXXTX.). 

12.  The  diseases  most  readily  confounded  with  hydatid  of 
the  liver  are  abscess,  distended  gall-bladder,  effusion  into  the 
right  pleura,  aneurism,  cancer,  cystic  tumour  of  the  kidney, 
phantom  tumour,  and  ovarian  cyst. 

a.  The  absence  of  symptoms,  both  constitutional  and  local, 
and  the  slow  growth  of  hydatid  tumour  form  a  marked  dis- 
tinction between  it  and  abscess,  which,  so  far  as  its  physical 
characters  are  concerned,  is  the  form  of  hepatic  enlargement 
most  closely  resembling  hydatid.  There  is  one  source  of  fal- 
lacy, however,  which  must  be  kept  in  view,  although  an 
accurate  diagnosis  under  the  circumstances  would  not  materially 
modify  the  prognosis  or  the  treatment.  A  hydatid  tumour 
of  the  liver  occasionally  inflames  and  suppurates,  and  then  it 
may  present  all  the  constitutional  and  local  phenomena  of 
abscess.  The  diagnosis  of  this  condition  must  depend  entirely 
on  the  patient's  previous  history — the  fact  of  a  painless  tumour 
having  long  preceded  the  symptoms  of  abscess,  the  absence  of 
exposure  to  the  ordinary  causes  of  tropical  a,bscess,  and  the 
absence  of  any  history  of  dysentery. 

h.  A  distended  galL-bladder  may  closely  resemble  a  pendu- 
lous hydatid  of  the  liver,  and  may  also  be  free  from  pain.  It 
is  recognised  by  its  shape  and  position,  by  its  development 
being  usually  preceded  by  attacks  of  biliary  colic,  and  by 
the  fact  that  in  most  cases  there  is  jaundice,  from  obstruc- 
tion of  the  common  duct.  It  must  not  be  forgotten,  how- 
ever, that  when  a  hydatid  opens  into  a  bile  duct,  the  contents 
of  the  cyst  in  their  passage  along  the  duct  may  give  rise 
to  all  the  phenomena  of  biliary  colic,  including  jaundice. 
Sir  Thomas  Watson  has  recorded  a  remarkable  instance  of 
this  sort,^  and  several  have  come  under  my  own  notice,  the 
j)articulars  of  which  I  shall  presently  relate  to  you. 

c.  Extensive  effusion  into  the  right  pleura,  with  bulging  of 
the  ribs  and  obliteration  of  the  intercostal  spaces,  may  closely 
simulate  a  large  hydatid  tumour ;  but,  on  the  whole,  a  hydatid 
of  the  liver  is  more  likely  to  be  regarded  as  an  example  of 
pleuritic  effusion,  than  pleuritic  effusion  mistaken  for  hydatid. 
The  hydatid  is  mainly  distinguished  by  its  insidious  growth, 
and  by  the  absence  of  constitutional  symptoms.  The  chief 
physical  distinction  is  derived  from  the  upper  boundary  of  the 

Lectures,  otli  edition,  1871,11.,  632  j  also  Trousseau,  op.  cit.  IV.  pp.  23",  276. 


6o  ENLARGEMENTS    OP    THE    LIVER.  i.Kcr.  iii. 

dull  space.  In  pleuritic  effusion  this  is  horizontal  (page  10)  ; 
in  hydatid  tumour  it  is  arched,  the  convexity  of  the  arch 
varying  in  its  position  with  that  of  the  tumour  in  different 
cases,  but  always  fixed  in  the  same  patient.  The  possibility, 
however,  of  a  hydatid  of  the  liver  co- existing  with  pleuritic 
effusion  must  not  be  lost  sight  of  (see  Cases  XXXIX.,  XL.)  ; 
under  such  circumstances  the  diagnosis  may  be  extremely 
difficult.  Moreover,  an  encysted  pleurisy  may  simulate  hyda- 
tid hj  producing  a  circumscribed  bulging  of  the  lower  ribs,  not- 
withstanding what  Trousseau'  says  to  the  contrary  (see  ]).  16). 

d.  An  aneurism  of  the  abdominal  aorta,  or  of  the  hepatic 
artery,  may  present  a  smooth,  globular  tumour,  very  like  that 
of  a  hydatid.  Its  main  distinctive  characters  are  pulsation, 
bellows-murmur,  and  the  fact  that  it  is  usually  the  seat  of 
acute  neuralgic  pains,  owing  to  pressure  on  the  branches  of  the 
solar,  or  of  the  hepatic,  plexus.  An  aneurism  of  the  hepatic 
artery  is  further  distinguished  by  its  being  accompanied  by 
jaundice  from  compression  of  the  bile- ducts. 

e.  Cancer  of  the  liver  is  mainly  distinguished  by  its  irregu- 
lar surface,  tenderness  and  hardness,  and  by  the  absence  of 
elasticity  or  feeling  of  fluctuation.  The  diagnosis  may  be 
embarrassed  by  the  circumstance  that  several  hydatid  tumours 
projecting  from  the  surface  of  the  liver  may  impart  to  it  an 
uneven  surfiice  (Case  XLV.),  or  that  the  nodules,  or  an  exten- 
sive infiltration,  of  medullary  cancer  may  exhibit  a  degree  of 
elasticity  approaching  to  fluctuation,  or  that  in  rare  cases  a 
large  cyst  may  be  developed  in  the  liver  in  conjunction  with 
cancer  (Case  XCVI.).  Under  such  circumstances,  the  dia- 
gnosis of  hydatid  must  mainly  depend  on  its  slower  growth  and 
on  the  absence  of  constitutional  cachexia. 

/.  Renal  Cyst.  I  have  already  had  occasion  to  refer  to  the 
difficulties  in  distinguishing  between  a  large  renal  cyst  and  an 
enlarged  liver  (page  14).  A  renal  cyst  is  distinguished  from 
a  hydatid  of  the  liver  by: — 1,  its  place  of  origin  and  direction 
of  groAvth  ;  2,  the  presence  of  colon  in  front  of  the  cyst ;  and  3,  its 
position  being  little,  if  at  all,  influenced  by  deep  inspiration. 
The  characters  of  the  fluid  obtained  by  exploratory  jiuncture 
will  not  assist  you  much  in  diagnosis.  There  will  of  course  be 
no  echinococci  or  fragments  of  hydatid  cyst,  but  you  may  fail 
to  find  these  in  the  fluid  drawn  off  from  a  hydatid.  On  the 
other  hand,  the  fluid  may  have  a  specific  gravity  of  1010,  and 
may  contain  no  urea,  but  abundance  of  chlorides  with  pus  and 

>  Op.  cit.  iv.  267. 


XECT.  III.  HYDATID   TUMOUE.  6 1 

albumen,  characters  wlaicli  are  quite  compatible  witli  tlie  fluid 
from  an  inflamed  hydatid  (Case  VIII.). 

g.  A  circumscrihed  Phantom  Tumour  in  the  epigastrium  or 
right  hypochondrium  may  be  mistaken  for  a  hydatid.  Not  long 
ago  I  saw  a  case  in  my  private  practice  where  this  mistake  was 
committed  (Case  YII.).  It  is  distinguished  by  the  absence  of 
fluctuation  or  vibration,  and  by  the  circumstance  that  the 
tumour  disappears  when  the  patient  is  put  fully  under  the 
influence  of  chloroform. 

h.  Ovarian  Cyst.  There  is  rarely  any  difficulty  in  dis- 
tinguishing between  a  cjsi  of  the  liver  and  an  ovarian  cyst. 
The  main  distinguishing  characters  of  a  hepatic  cyst  are  :— 
1.  Its  growth  from  above  downwards ;  2,  the  hand  can  be 
passed  between  its  lower  margin  ard  the  brim  of  the  pelvis; 
3,  its  lower  margin  is  depressed  by  deep  inspiration ;  4,  the 
enlargement  is  usually  greater  above  the  level  of  the  umbilicus 
than  below ;  5,  the  examination  of  the  fluid  obtained  by  ex- 
ploratory puncture  would  at  once  remove  all  difficulty  in  the 
diagnosis.  There  may,  however,  be  some  difficulty  when  a 
hepatic  cyst  is  seen  for  the  first  time  after  it  has  attained  a 
large  size ;  and  not  long  ago  a  case  was  recorded  in  one  of  the 
medical  journals  where  the  operation  of  ovariotomy  was  com- 
menced in  what  proved  to  be  a  cyst  of  the  liver.  ^ 

If  there  be  any  doubts  as  to  the  nature  of  the  case,  they 
may  in  most  cases  be  removed  by  an  exploratory  puncture. 
The  fluid  which  escapes  from  a  hydatid,  even  if  it  contain  no 
echinococci  or  shreds  of  striated  hydatid  membrane,  will  reveal 
its  nature  with  absolute  certainty.  If  the  sac  be  not  inflamed 
it  is  limpid,  when  running  in  a  stream,  with  a  slight  opalescence 
when  viewed  in  bulk  ;  it  is  alkaline,  and  has  a  s^^ecific  gravity 
of  1009  (1007-1011)  ;  it  contains  neither  albumen  nor  urea 
but  throws  down  a  copious  white  precipitate  with  nitrate  of 
silver,  owing  to  its  strong  impregnation  with  common  salt. 
These  characters  apply  to  no  other  fluid  in  the  body,  whether 
healthy  or  morbid.^     Even  if  the  case  should  turn  out  to  be  an 

'  Brit.  Med.  Journ.,  Dec.  5,  1874.  lu  this  case,  the  slow  progress,  the  absence  of 
irregularities  from  the  surface,  and  the  decided  fluctuation  were,  in  my  opinion  no 
arguments  against  hydatid  tumour,  as  Avas  contended, 

-  The  contrast  between  the  fluid  in  the  hydatid  cysts  described  in  CaseXLIV.  and 
the  surrounding  peritoneal  fluid,  in  which  they  were  floating,  is  worth}-  of  notice. 
According  to  Naunyn,  hydatid  fluid  has  a  specific  gravity  of  1010  to  1013,  and  con- 
tains some  albumen,  hut  tliis  is  contrary  to  my  experience  except  when  tlie  sac  is  in- 
flamed, or  blood  has  become  mixed  with  it. 


62  ENLARGEMENTS    OF    THE    LIVEE.  ikct.  hi. 

aneurism   or  a  cancer,  no  harm  is  likely  to  result  from  an 
exploratory  puncture. 

Modes  of  Termination  of  Hydatid  Tumours  of  the  Liver. — 
It  may  be  tliouglit  tliat  a  tumour  which  causes  so  little  incon- 
venience, that  even  when  of  large  size  the  patient  himself  may 
be  ignorant  of  its  existence,  requires  little  interference  in  the 
way  of  medical  treatment.  In  reference  to  practice  it  is  there- 
fore important  to  have  a  correct  knowledge  of  the  natural  modes 
of  termination  of  hydatid  tumours  of  the  liver.  The  chief  of 
these  are  as  follows  : — 

^Spontaneous  Cure. — In  the  first  place,  there  can  be  no  doubt 
that  some  of  these  tumours  undergo  a  spontaneous  cure.  The 
parasite  may  die  from  calcification  of  the  parent  cyst  prevent- 
inn-  further  growth,  from  inflammatory  action  lighted  up  by 
the  entrance  of  bile  or  by  some  other  cause,  or  from  the  secon- 
dary vesicles  increasing  out  of  all  proportion  to  the  fluid  in 
which  they  float  (Case  XLYII.) ;  the  parent  cyst  slowly  shrivels 
up,  and  in  place  of  the  hydatid  we  find  a  putty-like  material, 
the  real  nature  of  which  is  disclosed  by  its  containing  shreds 
of  the  striated  hydatid  membranes  or  booklets  of  echinococci. 
But,  unfortunately,  this  favourable  result  is  confined  for  the 
most  part  to  tumours  of  so  small  a  size  that  the}^  are  not 
recoo-nised  during  life.  Case  XL VIII.  is  a  remarkable  excep- 
tion to  the  general  rule  in  this  matter.  Watson  also  {op.  cit. 
ii.  635)  diagnosed  a  hydatid  cyst  in  a  young  nobleman,  who 
died  22  years  afterwards,  when  a  shrivelled  hydatid  was  found 
in  the  liver.  When  the  tumour  is  sufficiently  large  to  give 
rise  to  symptoms  and  be  diagnosed,  such  an  event  is  so  excep- 
tional that  it  cannot  be  calculated  on.  The  tumour  then 
continues  to  increase  in  size.  Its  growth  may  be  slow ;  it 
may  extend  over  years ;  but  almost  as  surely  as  the  tumour 
grows  will  it  one  day  burst,  or  lead  to  an  equally  dangerous 
though  less  sudden  result.  Even  a  cyst  which  has  undergone 
apparently  a  spontaneous  cure,  may,  as  Dr.  Church  has  shown, 
light  up  fatal  inflammation.^  The  directions  in  which  a  hyda- 
tid tumour  of  the  liver  may  burst  are  very  various,  and  the 
danger  will  vary  accordingly. 

1.  Into  til  c  Pleural  Cavity  or  Pulmonary  Tissue. — This  direc- 
tion is  more  common  than  any  other.     It  is  almost  always  the 
right  lung  and  pleura  that  are  invaded.     When  the  contents 
of  the  hydatid  are  discharged  through  an  opening  in  the  dia- 
'  Treatment  of  Hydatid  Tumours  of  Liver,  1868.     See  also  Case  XLI. 


XECT.  in.  HYDATID   TUMOUE.  63 

pliragm  into  the  pleura,  acute  and  almost  invariably  fatal 
pleurisy  is  the  result.^  After  death  the  pleural  cavity  is  found 
full  of  pus  containing  numerous  hydatid  cysts  (Case  XXXIX.). 
Trousseau  has  recorded  cases  in  which  an  empyema  thus  induced 
has  subsequently  burst  into  a  bronchial  tube.  Fatal  pleurisy 
may  also  result  from  a  hydatid  tumour  of  the  liver,  without 
any  perforation  of  the  diaphragm.^ 

If  adhesions  form  between  the  diaphragm  and  the  base  of 
the  right  lung  prior  to  the  bursting  of  the  hydatid,  the  contents 
of  the  latter  may  escape  along  with  bile  by  the  bronchial  tubes, 
and  the  patient  may  recover  f  but  even  here,  in  most  cases, 
fatal  inflammation  or  gangrene  is  set  up  in  the  lung,.:*  or  the 
patient  dies  of  suffocation  from  occlusion  of  the  bronchi  by 
hydatid  cysts,  or  of  exhaustion,  owing  to  profuse  discharge 
from  one  or  several  cavities  excavated  in  the  lung.^  From 
Case  XLI.,  also,  it  will  be  seen  that  an  obsolete  hydatid  cyst 
of  the  liver  may  inflame,  and,  after  establishing  a  communica- 
tion with  the  bronchial  tubes,  may  give  rise  to  all  the  phenomena 
of  gangrene  of  the  lung. 

2.  Into  the  Pericardium. — This  is,  fortunately,  a  very  rare 
direction,  as  the  cases  in  which  it  has  been  noticed  have  been 
always  fatal,  either  instantaneously  by  embarrassment  of  the 
heart's  action,  or  within  a  few  hours  by  acute  pericarditis.^ 

3.  hito  the  Peritoneum. — The  tumour  collapses,  and  violent 
and  almost  always  fatal  peritonitis  is  at  once  excited.  This 
accident  must  not  be  confounded  with  the  attacks  of  partial 
peritonitis  which  are  so  common  before  the  tumour  bursts  in 
other  directions.  The  rupture  of  the  sac  is  often  caused  by 
external  violence,  in  the  form  of  a  blow,  fall,  or  strain.  In  the 
museum  of  St.  Mary's  Hospital  is  the  calcified  cyst  of  a  hydatid, 
taken  from  the  body  of  a  man  who  dropped  down  dead  after 

1  See  Cases  XXXIX.  and  XL. ;  also  Frerichs,  Dis.  of  Liver  (Syd.  Soc.  Ed.),  ii.  235  ; 
Ogle,  Path.  Trans,  xi.  299  ;  Bristowe,  Path.  Trans,  iii.  341 ;  H.  Davies,  Path.  Trans. 
i.  278 ;  Davaino,  Traite  des  Entozooaires,  p.  437  :  into  left  lung,  P.  W.  Latham 
Lancet,  Ang.  16,  1873. 

2  See  Murchison,  Ed.  Med.  Journ.  Dee.  1865,  Case  XL,  and  case  hj  Dr.  Pollock, 
Path.  Trans,  v.  301. 

'  For  examples,  see  Bright,  Abdom.  Tiim.  (Syd.  Soc.  Ed.),  p.  49 ;  Todd,  Med. 
Times  and  Gazette,  Jan.  5,  1854 ;  Path.  Trans,  iv.  44 ;  v.  303  ;  viii.  92  •  ix.  28  • 
Davaine,  op.  cit.  p.  449. 

''  See  cases  by  Peacock,  Path.  Trans,  ii.  72  ;  Pollock,  ib,  xvi.  155. 

*  Frerichs,  op.  cit.  ii.  264 ;  Peacock,  Path.  Trans,  vol.  xv.  p.  247 ;  Cayley,  ib. 
xxvii.  171  ;  Davaine,  op.  cit.  p.  443. 

"  Two  cases  of  nipture  into  the  pericardium  will  be  found  in  Davaine's  work  (p. 
408);  a  third  is  recorded  1  ly  Wuuderlich  (Med.  Times  and  Gaz.  Nov.  ]2,  1859,  p.  488). 


64  ENLAEGEMENTS    OF    THE    LIVER.  lect.  tit. 

receiving  a  slight  blow  on  the  epigastrium  from  a  comrade  with 
whom  he  was  sparring.  The  blow  ruptured  the  cyst;  the 
contents  of  the  cyst  escaped  into  the  peritoneum,  and  the  man 
died  from  shock.  Many  years  ago  Andral  reported  a  case 
of  hydatid  of  the  liver  terminating  fatally  by  rupturing  spon- 
taneously into  the  peritoneum. ^  Three  cases  of  fatal  rupture 
in  consequence  of  a  fall  are  recorded  by  Mr.  Csesar  Hawkins.^ 
Three  similar  cases  are  mentioned  by  Frerichs ;  in  two  the 
rupture  was  caused  by  a  fall,  and  in  the  third  it  was  due  to  a 
strain ;  in  one  of  the  cases,  death  occurred  within  a  quarter  of 
an  hour  of  the  rupture.  Eight  additional  cases  have  been 
collected  by  Davaine  in  which  death  ensued  within  a  few  hours 
or  days  of  the  rupture  of  a  hydatid  of  the  liver  into  the  perito- 
neum ;  in  several  of  the  cases  the  rupture  was  caused  by  a  fall 
or  strain,  and  in  one  it  occurred  while  the  patient  was  wrestling 
with  a  comrade.^  Eupture  into  the  peritoneum  was  probably 
the  cause  of  the  fatal  event  in  Case  XLII.  On  the  other  hand. 
Bright  records  a  case  where  what  appeared  to  be  a  large  hj-da- 
tid  tumour  of  the  liver  burst  into  the  abdomen,  without  being 
followed  by  a  fatal  result."*  Ogle  also  mentions  the  case  of  a 
patient  who  recovered  after  the  symptoms  of  peritonitis  result- 
ing from  the  rupture  of  a  hydatid  cyst  in  the  omentum.'* 
Lastly,  Dr.  Fagge  and  Mr.  Durham  have  found  that,  when 
needles  were  introduced  into  a  hydatid  of  the  liver,  the  fluid 
contents  of  the  cyst  seemed  to  ooze  through  into  the  peritoneum 
without  any  bad  result.*^  These  different  results  are,  perhaps, 
due  to  the  presence  or  absence  of  scolices  and  secondary  cysts 
in  the  fluid  which  escapes,  the  entrance  of  the  simple  hydatid 
fluid  into  a  serous  cavity  being,  as  Malgaigne  has  contended, 
harmless.^  But,  inasmuch  as  it  is  the  exception  for  a  hydatid 
to  be  barren,  and  there  are  no  means  of  determining  during  life 
whether  it  be  so  or  not,  its  rupture  into  the  peritoneum  must 
always  be  regarded  with  dread. 

4.  Througli  the  Abdominal  Parietes  or  Lower  Intercostal 
Spaces. — This  is  not  a  common  mode  of  termination,  although 
several  cases  are  on  record.  The  contents  of  the  hydatid  may 
be  discharged  by  an  opening  at  the  umbilicus  or  in  some  other 
part  of  the  abdominal  parietes,  or  in  one  ofthe  lower  intercostal 
spaces,  and  the  patient  may  get  well.     Even  here,  however,  the 

'  Clin.  Med.,  Malad.  do  rAbdonicn,  xliv.  ubs. 

*  Med.-Chir.  Trans,  vol.  xviii.  p.  124.  ^  ]);iv;ii)ie.  op.  cit.  p.  493. 

*  Abdom.  Tumours,  Syd.  Soc.  Ed.  p.  47.  "  I'atli.  Trans,  xi.  p.  295. 

«  3Ied.-Chir.  Trans,  vol.  liv.,  1871.  ;  Traite  do  Med.  Opdrat.  6™-=  cd.  p.  521. 


LECT.  III.  HYDATID    TUMOUR.  65 

cyst  is  apt  to  take  on  suppuration,  and  the  patient  may  die 
from  exhaustion  or  from  peritonitis,  or  from  extensive  suppu- 
ration and  sloughing  of  the  abdominal  parietes ;  or  fatal 
liBemorrhage  may  occur  from  the  interior  of  the  sac,  as  in  a  case 
recorded  by  Dr.  Bright.  Of  twelve  cases  where  a  spontaneous 
opening  occurred,  and  of  which  I  have  collected  notes,  five  at 
least  terminated  fatally,  and  in  a  sixth  there  remained,  at  the 
date  of  the  report,  a  fistula  discharging  bile.  Four  also  out  of 
eleven  cases  observed  by  Finsen  in  Iceland  were  fatal.  ^ 

5.  l7ito  the  Stomach  or  Intestine.- — This  is  the  most  favour- 
able direction  in  which  the  tumour  can  burst,  although  death 
sometimes  results  from  the  peritonitis  which  is  set  up  around 
the  opening,  or  from  secondary  abscesses  of  the  liver,^  and 
unfortunately  it  is  not  a  common  mode  of  termination.  The 
tumour  becomes  flattened  or  disappears  ;  and  according  as  it 
opens  into  the  stomach  or  the  intestine,  the  hydatids  are  vomited 
or  evacuated  per  anum-,^  sometimes  they  escape  in  both  direc- 
tions. The  opening  is  usually  small,  so  that  the  hydatids  are 
discharged  slowly. 

Davaine  has  collected  eleven  cases  where  a  hydatid  tumour 
of  the  liver  appeared  to  open  into  the  stomach,  of  which  six 
were  fatal ;  and  fifteen  cases  where  there  was  reason  to  believe 
that  it  had  opened  into  the  intestine,  of  which  only  one 
was  fatal.  In  one  of  Davaine's  cases  the  tumour  opened 
through  the  abdominal  parietes,  as  well  as  into  the  stomach. 
In  a  case  of  large  hydatid  tumour  of  the  liver  which  occurred 
in  the  Middlesex  Hospital  in  1859,  under  the  care  of  my  friend 
Dr.  A.  P.  Stewart,  where  the  liquid  contents  were  drawn  off 
by  a  trocar,  the  tumour  subsequently  burst  into  the  bowel, 
discharging  numerous  cysts  -per  anum,  and  the  patient  made 
a  good  recovery.  In  the  '  Gazette  des  Hopitaux '  for  1850,  a 
remarkable  case  is  recorded  where  three  hydatid  cysts  of  the 
liver  opened  spontaneously,  the  first,  in  183S,  into  the  bronchi ; 
the  second,  in  1845,  into  the  stomach ;  and  the  third,  in 
1848,  into  the  intestine  :  the  patient  recovered.  Russell  also 
has  recorded  the  case  of  a  man  aged  36  who  had  two  large 

'  Eudd,  Dis.  of  Liver,  3rd.  ed.  p.  437;  Frerichs,  op.  cit.  ii.  p.  237;  Hawkins, 
Med.-Chir.  Trans,  xviii.  pp.  153,  158  ;  Bright,  op.  cit.  p.  50  ;  Griffiths,  Lond.  Med. 
Gaz.  1844,  vol.  xxxiv.  p.  585  ;  Davaine,  op.  cit.  p.  384,  Obs.  V. ;  Ogier  Ward,  Path. 
Trans,  iii.  100  ;  Kansom,  Brit.  Med.  Journ.  1873,  ii.  376. 

2  See  a  case  under  Dr.  Owen  Rees,  Med.  Times  and  Gaz.  June  20,  1857. 

'  For  examples,  see  Frerichs,  op.  cit.  ii.  p.  237  ;  Budd,  op.  cit.  p.  452  ;  Bright,  op. 
cit.  p.  49  ;  Davaine,  op.  cit.  p.  496. 

P 


66  ENLAEGEMENTS    OF    THE    LIVEE.  I-ect.  tit. 

hydatid  tumours  of  the  liver,  one  of  which  opened  into  the  right 
pleura,  and  the  other  into  the  stomach  and  the  bronchial  tubes 
of  the  left  lung-.' 

6.  Info  the  Urinary  Passages. — Although  hydatid  tumours 
of  the  abdomen  or  pelvis  occasionally  open  into  the  urinary 
passages,  echinococci  and  shreds  of  hydatid  membrane  being 
found  in  the  urine,-  I  have  met  with  no  case  where  this  has 
happened  when  the  primary  cyst  has  been  in  the  liver.  In 
1868  a  case  of  this  sort  is  said  to  have  occurred  in  one  of  the 
London  hospitals,^  but  it  is  not  clear  that  the  cyst  was  in  the 
liver,  or  that  it  was  a  hydatid. 

7.  Into  the  Biliary  Passages. — It  is  not  uncommon  for  a 
communication  to  be  established  between  a  hydatid  tumour  of 
the  liver  and  one  of  the  bile-ducts.  In  several  cases  where 
this  has  occurred,  I  have  found  the  secondary  cysts  ruptured, 
empty,  and  more  or  less  stained  with  bile.  The  entrance  of 
bile,  as  was  long  ago  stated  by  Cruveilhier,  appears  to  be  fatal 
to  the  life  of  the  parasite,  and  in  many  cases  probably  consti- 
tutes the  commencement  of  a  spontaneous  cure,  while  in  other 
cases  it  lights  up  severe  and  even  fatal  inflammatory  action  in 
the  cyst  (Case  XXXII,).  Not  only  does  bile  enter  the  cyst, 
but  occasionally  the  contents  of  the  C3^st  pass  into  the  bile- 
ducts  and  gall-bladder,  causing  obstruction  of  these  passages, 
Avith  persistent  and  often  fatal  jaundice.  In  several  instances 
the  passage  of  secondary  cysts  along  the  bile-ducts  has  given 
rise  to  all  the  symptoms  produced  by  passing  a  gall-stone. 
You  have  had  opportunity  of  watching  cases  of  this  sort  (Cases 
XXXI.  to  XXXIV.),  and  several  others  will  be  found  in 
Davaine's  work.''  In  one  of  the  cases  which  have  been  under 
your  notice,  the  jaundice  almost  disappeared,  although  the  stools 
remained  colourless,  in  consequence  of  the  bile  draining  away 
through  the  opening  in  the  abdominal  parietes  (Case  XXXII.). 
Mr.  Hawkins  has  recorded  a  case  where  the  common  bile-duct 
was  obstructed  by  hydatids,  without  jaundice,  o\ving  to  the  bile 

>   Med.  Times  and  Gaz.  1873.  i.  439. 

2  For  several  cases  see  Med.  Times  and  Gaz.  1855,  i.  169. 

»  Brit.  Med.  Journ.  Nov.  7,  1868. 

♦  Op.  cit.  p.  462.  In  rave  instances  a  hydatid  tumour  appears  to  be  developed  in 
tlie  bile-duct,  although  the  possibility  of  such  an  occurrence  is  denied  by  Davaine. 
Dr.  Dickinson  has  recorded  tlio  case  of  a  hydatid  developed  in  the  ri<j;lit  hepatic  duct, 
where  olistruction  of  the  common  duct  wns  caused  liy  a  portion  of  the  cyst,  together 
with  inspissated  bile  (Path.  Trans,  xiii.  104). 


i.ECT.  III.  HYDATID    TUMOUR.  6/ 

escaping  by  a  fistulous  opening  into  a  bronchus.'  But  now  and 
then  the  biliary  passages  become  sufficiently  dilated  to  permit 
the  evacuation  of  the  contents  of  the  cyst  through  them  into 
the  bowel.  This  is  a  rare  occurrence,  and  most  of  the  cases 
where  it  has  been  noticed  have  been  fatal.  A  remarkable  case 
is  recorded  by  Dr.  Hillier,  where  the  contents  of  a  hydatid 
tumour  were  discharged  through  the  bile-duct  into  the  bowel, 
but  where  the  patient  died  in  consequence  of  haemorrhage  from 
the  wall  of  the  cyst,  tlie  blood  (derived  apparently  from, 
branches  of  the  hepatic  artery)  passing  along  the  duct  into  the 
stomach  and  intestines.^  Leudet  reports  a  case  of  hydatid  of 
the  liver  opening  into  a  bile-duct;  the  patient  died  four  weeks 
after  the  appearance  of  jaundice,  and  the  extremities  of  the 
hepatic  duct  in  the  liver  were  found  to  be  distended  with  pus.^ 
Two  cases  are  recorded  by  Dr.  Wilks,  where  a  hydatid  cyst 
opened  into  a  bile-duct,  but  where  death  was  caused  by  perito- 
nitis or  by  '  inflammation  about  the  liver  and  ducts ; '  in  one 
of  the  cases  hydatid  cysts  had  been  vomited  and  passed  from 
the  bowel  before  the  occurrence  of  inflammation.^  Frerichs 
mentions  a  case  where  most  of  the  contents  of  a  hydatid  had 
escaped  by  the  bile-duct,  but  where  the  common  duct  ulti- 
mately became  obstructed,  and  fatal  rupture  of  the  gall-bladder 
was  the  result.^ 

Case  XXXiy.  is  an  example  of  recovery  after  the  discharge 
of  the  contents  of  a  large  hydatid  cyst  through  the  bile-duct 
into  the  bowel ;  but  although  the  recovery  appeared  to  be  com- 
plete, several  months  afterwards  the  passage  of  some  of  the  re- 
maining contents  of  the  tumour  along  the  duct  gave  rise  to 
severe  pain  and  vomiting,  and  the  muscular  efforts  in  vomit- 
ing tore  across  some  of  the  old  adhesions:  the  result  was  fatal 
peritonitis. 

In  Sir  Thomas  Watson's  case,  already  referred  to  (p.  59),  the 
patient  for  eight  or  ten  years,  at  intervals  varying  from  ten  to 
fourteen  months  in  duration,  had  suffered  a  series  of  attacks 
precisely  such  as  are  commonly  produced  by  the  passage  of  a 
biliary  concretion  through  the  ducts  of  the  liver.  In  May, 
1847,  just  after  one  of  these  attacks,  while  searching  for  a  gall- 
stone, he  discovered  two  or  three  small  hydatids  in  the  fseces. 
In  July  he  had  the  same  symptoms  for  four  or  five  days,  and 

>  Med.-Chir.  Trans.  xTiii.p.  148.  *  Path.  Trans,  vii.  p.  222, 

■     s  Clin,  med.,  Paris,  1874,  p   412.  •'  Path.  Trans,  xi.  p.  128. 

'  Op.  cit.  ii.  p.  231.  ^^  ,.  <D  f  >"E  H  Tl 


6S  ENLARGEMENTS    OF    THE    LIVEE.  tlect.  hi. 

then  vomited  a  hydatid  as  large  as  a  pigeon's  egg.  This  attack 
Avas  followed  by  pulmonary  symptoms,  and  in  August  he  began 
to  expectorate  hydatids  with  large  quantities  of  bile.  The 
liydatids  ceased  to  appear  towards  the  end  of  November ;  the 
bile  in  the  second  week  of  February,  1848.  After  this  he 
recovered ;  and  twenty- three  years  afterwards  he  was  alive  and 
i]i  good  health,  and  in  active  practice  as  a  medical  man.'  In  a 
case  referred  to  by  Trousseau,  the  opening  of  the  cyst  into  the 
bile-duct  gave  rise  to  biliary  colic,  which  lasted  for  three 
-weeks ;  upwards  of  three  years  afterwards  there  was  a  second 
attack  of  hepatic  colic,  followed  by  rupture  of  the  cyst  into  the 
pleura  and  death. ^  Quite  recently  a  very  similar  case  has 
been  observed  by  Di-.  George  Johnson,^  but  the  patient  died 
of  acute  peritonitis.  The  only  other  case  of  recovery,  under 
like  circumstances,  which  I  have  met  with,  is  one  referred  to  by 
Davaine,  where  there  was  reason  to  believe  that  a  hydatid  of 
the  liver  had  ruptured  into  the  gall-bladder,  and  where  the 
patient  recovered  after  a  severe  attack  of  biliary  colic  and 
jaundice,  accompanied  by  the  passage  per  anum  of  both  hyda- 
tid cysts  and  gall-stones.^ 

8.  Into  the  Portal  Vein. — A  hydatid  of  the  liver  occasionally 
opens  into  the  portal  vein  or  one  of  its  branches.  In  a  case 
where  this  had  occurred,  Leudet  found  numerous  secondary 
abscesses  in  the  liver.^ 

9.  Into  the  Vena  Cava  Inferior. — In  exceptional  cases,  a 
hydatid  of  the  liver  bursts  into  the  inferior  vena  cava,  and  its 
contents,  reaching  the  right  side  of  the  heart,  become  impacted 
in  the  pulmonary  artery  and  cause  instant  death.  Three  cases 
of  this  sort  are  mentioned  by  Frerichs.*^ 

But,  independently  of  rupture,  there  are  various  ways  in 
which  a  hydatid  tumour  may  destroy  life. 

1.  By  Marasmus  and  Exhaustion. — This  was  the  mode  of 
death  in  Case  XXXVIII.,  where  a  hydatid  of  the  liver  became 
so  large  that  the  entire  abdomen  was  enormously  distended  by 
it,  and  respiration  was  seriously  embarrassed.  This  case  was 
further  remarkable  from  the  circumstance  that  there  were  dul- 
ness  and  fluctuation  over  the  greater  part  of  the  front  of  the 

'  Lectures  Sth  ed.  1871,  ii.  631.  «  Op.  cit.  iv.  285. 

"  Med.  TJmcHand  G;iz.,  Jan.  ],  1876,  p.  2.  *  Op.  eit.  p.  477. 

•  Op.  cit.  p.  16. 

•  Op.  cit.  ii.  p.  238.     Two  of  these  cases  arc  related  at  greater  length  bj  Davaino 
(op.  cit.  p.  405). 


LECT.  iir.  HYDATID    TUMOUR.  69 

distended  abdomen,  while  the  epigastrium  and  both  flanks  were 
tympanitic  on  percussion. 

2.  By  Pressure  upon  important  Organs  and  Interference  with 
their  Functions. — A  hydatid  tumour  of  the  liver  may  compress 
the  vena  cava  so  as  to  cause  anasarca  and  varices  of  the  lower 
extremities,^  or  the  portal  vein,  so  as  to  induce  ascites  and 
necessitate  recourse  to  j)aracentesis.^ 

By  pressure  upwards  also  it  may  rise  as  high  as  the  second 
rib  or  the  clavicle  and  greatly  embarrass  the  respiration  and  the 
action  of  the  heart ;  and  by  pressure  on  the  stomach  and  intes- 
tines it  may  interfere  with  the  function  of  assimilation,  and 
cause  various  dyspeptic  symptoms,  emaciation  and  cachexia. 

3.  By  Suppuration  or  Gangrene  of  the  Cyst,  or  Suppuration 
external  to  the  Cyst,  with  or  ivithout  Pywmia  and  Secondary 
Purulent  Deposits.— Cases  XXXII.  XXXIII.  XXXV.  and 
XXXVI.  afford  illustrations  of  these  modes  of  termination,  and 
many  similar  cases  are  on  record.^  Bristowe  has  recorded  a 
case  where  the  secondary  abscesses  appeared  due  to  obstruction 
of  one  of  the  ducts,''  and  in  many  cases  pus  has  been  found  in 
the  vein  in  the  neighbourhood  of  the  suppurating  hydatid. 

4.  By  the  Formation  of  Secondary  Hydatid  Tumours.^ — 
Secondary  hydatid  tumours  may  form  in  the  liver  or  mesentery  ;  ^ 
by  a  process  of  exo^'enous  growth,  such  as  happens  more  fre- 
quently in  the  hydatids  which  infest  some  of  the  lower  animals. 
Cases  have  been  observed  in  the  human  liver  in  which  a  second- 
ary cyst  budded  from  the  outer  surface  of  the  parent  hydatid  ;  ^ 
and,  if  they  be  large  or  numerous,  they  may  interfere  with  the 
patient's  nutrition,  and  cause  death  by  exhaustion,  by  perito- 
nitis, or  by  uraemia  from  compression  of  the  ureters,  as  in  Case 
XLIII.  Not  uncommonly  they  form  in  the  lung,  and  destroy 
life  by  inducing  pneumonia.  Cases  XXVII.  to  XXIX.  are 
examples     of    secondary    hydatids     of    the    peritoneum    and 

'  A  case  of  this  sort  is  recorded  by  Dr.  Habershon,  in  Guy's  Hospital  Eeports,  3rd 
ser.  vol.  vi.  p.  182. 

2  See  cases  by  Dr.  Barker,  Path.  Trans,  vol.  vii.  p.  225,  and  by  Dr.  Budd,  Dis.  of 
Liver,  p.  451,  and  Hawkins  in  Med.-Chir.  Trans,  xviii.  p.  149. 

3  For  examples,  see  Bright,  op.  cit.  p.  37  ;  Budd,  op.  cit.  p.  444  ;  and  Frerichs,  op. 
cit.  ii.  p.  245. 

*  Path.  Trans,  vol.  ix.  p.  290. 

*  See  cases  recorded  by  Bright,  op.  cit.  pp.  13,  23,  and  30  ;  Jones,  Path.  Trans,  v. 
298  ;  Peacock,  ib.  247  xv. ;  Gibb,  ib.  xvi.  157. 

^  This  statement,  which  appeared  in  the  first  edition  of  these  lectures,  has  been 
denied,  but  I  have  the  authority  of  Dr.  Cobbold  for  its  correctness. 
'  Lect.  on  Path.  Anat.,  Wilks  and  Moxon,  2d.  ed.  p.  460. 


70  ENLARGEMENTS    OF    THE    LIVEE.  lect.  hi. 

mesentery  ;  Case  XXIX.  was  remarkable  for  the  successful 
removal  of  the  secondary  cysts  by  Mr.  Spencer  Wells.  Case 
XXIV.  is  an  instance  of  a  secondary  hydatid  tumour  compress- 
ing the  spinal  cord,  and  causing-  paraplegia.'  Dr.  Barker 
relates  the  particulars  of  a  case  where  death  was  due  to  the 
formation  of  a  secondary  hydatid  in  the  brain.^  An  interesting 
case  is  recorded  b}^  Dr.  Wilks,  of  a  girl,  aged  nineteen,  who 
died  suddenly,  having  previously  been  in  good  health ;  a  hyda- 
tid was  found  in  the  liver,  and  another  at  the  apex  of  the  left 
ventricle  of  the  heart;  the  latter  had  burst,  and  discharged  a 
loose  hydatid  into  the  cavity  of  the  left  ventricle.^ 

The  treatment  of  hydatid  tumours  of  the  liver  may  be  con- 
sidered under  the  following  heads. 

1.  Their  prophylaxis  is  based  on  a  knowledge  of  their  cause. 
Hydatid  tumours  in  man  are  develoj^ed  from  the  eggs  of  a  tape- 
worm which  enter  the  body  from  Avithout.  This  tape-worm, 
the  Twnia  echinococciis,  the  entire  length  of  which  does  not 
exceed  a  quarter  of  an  inch,  inhabits  the  intestine  of  the  dog 
and  wolf,  and  is  in  no  way  connected  with  the  jDig,  as  is  com- 
monly believed  to  be  the  case.  It  has  only  four  joints,  and  the 
ova  are  contained  in  the  last,  or  proglottis,  are  voided  with  the 
faeces  of  the  dog,  and  subsequently  find  their  way  into  the 
human  body  with  the  food  or  drink.  Arrived  in  the  intestines, 
they  are  developed  into  embryos,  which  penetrate  into  the 
liver  or  other  parts,  in  a  way  not  yet  satisfactorily  explained, 
and  are  there  developed  into  hydatid  tumours. 

But  the  ova  of  the  Twnia  echinococcus  develope  hydatids 
in  other  animals  than  man,  and  especially  in  the  sheep.  The 
hydatids  of  human  beings,  as  Dr.  Thudichum''  observes,  most 
frequently  accompany  them  to  their  graves,  or,  at  all  events, 
the}^  are  not  permitted  to  continue  their  dangerous  existence, 
but  the  echinococci  of  sheep  are  again  set  free  in  the  process 

'  Another  case  of  a  hydatid  of  the  spinal  column  pressing  on  tlie  cord  is  recorded 
by  Dr.  Ogle,  Path.  Tiaus.  p.  xi.  299. 

■^  I'atli.  Trans,  x.  p.  6. 

»  Patli.  Trans,  xi.  p.  71.  See  also  Path.  Trans,  xv.  p.  247.  Cases  of  hydatid 
tumours  of  the  heart,  without  any  implication  of  the  liver,  are  recorded  by  Haberslion 
(Path.  Trans,  vi.  p.  108),  I3udd  (Putli.  Trans,  x.  p.  80),  Peacock  (Path.  Trans,  xxiv. 
p.  37),  and  DaTaine,  op.  cit.  p.  ."^M.  In  Uudd's  case  a  hydatid  tumour  at  the  apex  of 
the  heart  had  burst,  and  loose  liydatids  were  found  in  the  right  ventricle  and  iu  the 
pulmonary  artery. 

*  Report  on  Parasitic  Diseases  in  Quadrupeds  used  as  Food,  in  Seventh  Report  of 
Med,  Off.  of  Privy  Council,  Loudon,  1865. 


XECT.  III.  HYDATID    TUMOUK.  J  \ 

of  slauglitering',  and  are  devoured  b}'  dogs,  to  be  again  deve- 
loped into  tape-worms.  While,  then,  man  does  not  contribute 
to  the  multiplication  and  propagation  of  echinococci,  his  con- 
stant liability  to  the  disease  is  kept  up  by  the  cycle  of  infection 
which  subsists  between  dogs  and  sheep. 

It  follows,  therefore,  that  for  the  prophylaxis  of  hydatid 
tumours  in  man  it  is  necessary : — 

a.  To  prevent  dogs  feeding  on  the  offal  of  sheep  and 
of  other  animals  infested  with  hydatids.  Dogs  ought  to  be 
rigidly  excluded  from  all  slaughter-houses  or  knackeries,  and 
*■  dogs'  meat '  ought  always  to  be  thoroughly  boiled. 

h.  To  destroy,  as  far  as  possible,  the  tape-worms  gene- 
rated in  the  dog,  for  which  purpose  it  would  be  well  that  all 
dogs  were  periodically  physicked,  and  their  excreta  buried  in 
the  ground  or  burnt. 

These  are  measures  which  are  of  national  importance  in 
such  countries  as  Iceland,  where  the  sheep-dog,  during  the 
long  nights  of  winter,  occupies  the  crowded  dwelling  of  his 
master,  and  where  hydatids  are  said  to  be  the  cause  of  one- 
seventh  of  the  human  mortality,  and  which  merit  attention 
even  in  our  own  country. 

2.  Medicines. — It  must  be  confessed  that  little  or  no  reliance 
can  be  placed  on  any  medicinal  agent  for  effecting  a  change  in 
the  size  or  in  the  structure  of  a  hydatid  tumour.  Among  the 
many  remedies  that  have  been  proposed,  common  salt  and 
iodide  of  potassium  are  the  two  which  have  been  most  relied 
on  for  destroying  the  life  of  a  hydatid,  but  there  is  no  evidence 
that  either  the  one  or  the  other  is  endowed  with  such  a  pro- 
perty. It  is  difficult  to  conceive  how  chloride  of  sodium  can 
be  unfavourable  to  the  growth  of  a  hydatid,  when  it  is  remem- 
bered how  large  a  quantity  of  this  salt  is  contained  in  the  fluid 
contents  of  the  cyst,  and  that,  therefore,  it  must  be  compatible 
with,  if  not  necessary  to,  the  healthy  existence  of  the  parasite. 
And  with  regard  to  the  preparations  of  iodine,  there  is  not  only 
no  proof  of  their  power  to  destroy  the  life  of  the  parasite,^  but 

'  The  following  are  references  to  instances  in  which  iodide  of  potassium  was 
thought  to  have  effected  the  cure  of  a  hydatid  cyst : — Med.  Times  and  G-az.  April  7, 
1860.  p.  34i,  and  Oct.  19,  1872,  p.  437  ;  Lancet,  Oct.  16,  1868;  Brit.  Med.  Journ. 
1871,  i.  499.  In  one,  at  least,  of  the  cases,  the  disappearance  of  the  tumour  appeared 
to  be  due  to  its  having  burst.  The  others  may  be  viewed  in  connection  with  a  case 
related  by  Dr.  P.  McGillivray,  where  a  hydatid  tumour,  which  it  was  intended  to  tap, 
disappeared  spontaneously,  a  few  days  after  the  patient's  admission  into  hospital 
(Austral.  Med.  Journ.  Aug.  1865).     As  Dr.  M.  remarks :  '  K  the  patient  had  been 


72  ENLARGEMENTS    OF   THE    LIVER.  XECT.  in. 

there  is  positive  evidence  that  tlie  iodine  does  not  reach  it. 
Frerichs  was  unable  to  discover  a  trace  of  iodine  in  the  fluid  of 
a  hydatid  cyst,  removed  from  a  woman  wlio  had  taken  iodide  of 
potassium  for  many  weeks,  and  similar  observations  were  made 
in  Cases  XVI.  XVII.  XVIII.  XIX.  Kamala,  which  was  ad- 
vocated some  years  ago  by  Dr.  Hjaltelin  of  Iceland,-  has  been 
tried  in  Australia  by  Dr.  Mac-Gillivray,  and  found  to  have  '  no 
influence  Avhatever  on  the  disease.'  '-^  After  the  life  of  the  para- 
site has  been  destroyed  by  opei'ation,  it  is  quite  possible  that 
such  remedies  as  the  iodide  and  bromide  of  potassium  may  be 
of  use. 

3.  Evacuation    of  the  Fluid    Contents  of  the   Cyst  hi/   a  fine 
Trocar  and  Cannula,   and    Closure  of  the    Opening. — Although 
medicines  are  of  little  or  no  avail,  there  is,  happily,  one  expe- 
dient which  holds  out  a  fair  chance  of  effecting  a  permanent 
cure,  and  that  is  puncture  of  the  cyst  and  removal  of  its  liquid 
contents.     It  is  now  many  years  (1822)  since  hydatid  tumours 
of  the  liver   were  tapjied   by  Sir    Benjamin  Brodie,   and  the 
patients  made  a  good  recovery. •'^     Successful  cases  were  after- 
wards published  by  Dr.  Bright,''  and  by  many  other  observers. 
It  is  only  of  late  years,  however,  that  the  operation   has  been 
often  resoi-ted  to,  and  even  still  it  is  ver\^  doubtful  if  most  prac- 
titioners would  not  prefer  leaving  the  patient  to  thf  very  un- 
certain chances  of  a  spontaneous  cure,  or  would  limit  the  opera- 
tion to  cases  where  the  tumor.r  is  of  a,  size  rarely  attained.    The 
fears  expressed  are  not  unnatural,  for  in  not  a  few  cases  the  opera- 
tion has  been  followed  by  dangerous  symptoms  or  even  death. 
The  dangers  of  the  operation  are  mainly  two;  viz.  1.  Acute 
peritonitis,  owing  to  the  escape  of  a  portion  of  the  hydatid 
contents  into  the  peritoneal  sac  ;  and,   2.  Suppuration  of  the 
cavity,  owing  to  the  admission  of  air,  and  to  the  collapse  of  the 
parasite  entailing  an  exudation  of  inflammatory  products  from 
the  vessels  in  the  outer  cyst. 

These  dangers  have  mainly  arisen  in  cases  where  an  open- 
ing has  been  made  with  a  scalpel  or  a  large  trocar,  on  the 
mistaken    supposition   that   it   w^as   necessary   to  remove   the 

getting  iodifle  of  potassium,  common  salt,  or  any  other  rpputod  specifip,  the  medicine 
would,  no  doul.t,  have  pot  the  credit  of  the  euro.'  Certain  it  is  that  in  hundreds  of 
cases,  iodide  of  potassium  lias  lieeii  taken  in  large  quantities,  without  producing  tlie 
slightest  change  in  the  tumour. 

'   Kdinh   M<'d.  Journ.,  Aug.  1867. 

"^  Australian  Med.  Journ.  July,  1872. 

"  Med.-Chir.  Trans,  vol.  xviii.  p.  lit).  *  Op.  cit.  p.  42. 


IKCT.  III.  HYDATID    TUMOUR.  73 

secondary  cysts  as  well  as  tlie  liquid,  or  because  tlie  tumour  was 
believed  to  be  an  abscess. 

But  the  dangers  in  question  may  be  in  a  great  measure 
avoided  by  employing  a  very  fine  trocar;  and,  in  the  case  of  a 
large  cyst,  by  removing  only  a  portion  of  the  liquid.  From 
Avhat  I  have  already  stated  (p.  64),  it  is  obvious  that  the  danger 
from  the  escape  of  the  hydatid  liquid,  without  scolices  or  se- 
condary cysts,  into  the  peritoneum  has  been  exaggerated.  Ex- 
perience also  has  shown  tha.t  the  removal  of  a  portion  of  the 
liquid  contents  (say  one-half  or  two-thirds)  is  all  that  is  neces- 
sary to  kill  both  the  parent  hydatid  and  its  offspring,  and 
accordingly  this  is  all  that  is  necessary  to  be  done.  When  a 
laT-ge  hydatid  is  completely  emptied,  there  is  a  corresponding 
outpouring  from  the  vessels  of  the  portion  of  liver  forming  the 
outer  wall,  and  a  greater  risk  of  subsequent  inflammation. 

The  administration  of  chloroform  before  the  operation  is 
not  advisable,  as  the  pain  is  but  momentary,  and  the  vomiting 
sometimes  induced  by  the  chloroform  interferes  with  that 
perfect  rest  of  the  parts  which  ought  always  to  be  insisted  on 
for  forty-eight  hours  after  the  puncture ;  but  if  the  patient  be 
young  or  nervous,  it  may  be  well  to  induce  local  anaesthesia  by 
the  ether-spray.  The  point  selected  for  puncture  ought  to  be  that 
where  the  hydatid  .fluid  appears  to  approach  nearest  to  the  sur- 
face. The  injection,  after  removal  of  the  fluid,  of  such  substances 
as  alcohol,  iodine,  oil  of  male  fern,  or  bile,  is  unnecessary,  and 
may  be  injurious,  by  exciting  excessive  inflammatory  action. 
Care  ought  to  be  taken  to  prevent  the  entrance  of  air,  and  for 
this  purpose  it  is  well,  even  in  the  case  of  a  small  cyst,  to 
remove  the  cannula  before  the  whole  of  the  fluid  has  been 
drawn  off,  or  as  soon  as  the  fluid  ceases  to  flow  in  a  full  stream, 
first  passing  a  wire  through  the  cannula  to  ascertain  whether 
the  stoppage  be  due  to  the  closure  of  its  orifice  by  a  hydatid 
vesicle.  Dr.  G.  Budd^  recommended  that  the  fluid  be  drawn 
off  by  means  of  an  exhausting  syringe,  adapted  to  the  cannula, 
and  more  recently  Dieulafoy's  aspirator  has  been  employed  for 
the  same  purpose;  but  on  several  occasions  (Case  XVI.)  when 
I  have  seen  Dr.  Budd's  apparatus  or  the  aspirator  employed, 
the  patient  experienced  so  much  pain  from  the  suction  action 
of  the  syringe,  or  blood  has  come  away  with  the  liquid,  that  I 
have  preferred  the  simpler  method  above  mentioned.  After 
removal  of  the  cannula,  the  opening  should  be  covered  with  a 

1  Med.  Times  and  Gaz.  May  19, 1860,  p.  494. 


74  ENLAKGEMENTS    OF    THE    LIVER.  lect.  in. 

piece  of  lint  steeped  in  collodion,  over  which  a  compress  and 
bandage  are  apjjlied,  and  for  forty-eight  hours  the  patient 
ought  to  be  kej)t  in  a  recumbent  posture,  and  every  movement  of 
the  body  be  strictly  prohibited  :  it  may  be  well  also  to  give  an 
opiate  at  once,  and,  if  there  be  the  slightest  pain,  this  may  be 
repeated  after  a  few  hours. 

One  advantage  of  using  a  fine  instrument  is  that  it  is 
unnecessary  to  wait  for  the  formation  of  adhesions  between  the 
tumour  and  the  abdominal  wall,  or  to  endeavour  to  induce  them 
by  measures  not  always  free  from  danger  before  puncturing, 
or  to  leave  the  cannula  in  for  twenty-four  hours  as  practised 
by  Jobert  de  Lamballe.'  The  walls  of  the  cyst  are  so  elastic 
that  the  small  opening  closes  immediately  that  the  instrument 
is  withdrav^n,  and  prevents  subsequent  oozing  from  the  interior. 
If  there  be  no  adhesions,  however,  one  precaution  ought  never 
to  be  neglected,  viz.  during  the  removal  of  the  cannula  to  press 
the  punctured  portion  of  the  abdominal  wall  against  the  cyst. 
By  neglecting  to  do  this  the  abdominal  wall  will  be  pulled  away 
from  the  cyst  in  the  extraction  of  the  cannula,  and  the  fluid  in 
the  cannula,  perhaps  containing  scolices,  ma}'  drop  into  the  peri- 
toneum. 

The  patient  often  experiences  immediate  relief  from  the 
sensation  of  tension  and  other  unpleasant  symptoms,  from 
which  he  may  previously  have  suffered,  and  within  three  or 
four  days  he  is  usually  up  and  walking  about.  Not  unfre- 
Cjuentl}'  an  eruption  of  urticaria'-  is  the  source  of  some  annoy- 
ance for  the  first  day  or  two  ;  in  most  cases  the  temperature  is 
elevated  from  two  to  four  degrees  for  several  days  ;  and  more 
rarely  the  operation  is  followed  by  a  feeling  of  uneasiness  in 
the  tumour,  or  by  considerable  pain  and  constitutional  disturb- 
ance ;  but  if  the  above  rules  be  attended  to,  these  symptoms 
soon  pass  off,  and  the  patient  makes  a  good  recover3\  It  not 
unfrequently  happens,  however,  that  about  a  week  or  ten  days 
after  the  operation  the  tumour  again  enlarges.  This  enlarge- 
ment is  not  due  to  a  re-accumulation  of  the  hydatid  fluid,  but 
to  inflammatory  products  thrown  out  between  the  collapsed 
jiarasite  and  the  surrounding  hepatic  tissue,  which  yre  slowly 
re-absorbed.     Under  these  circumstances  it  is   well  not  to  be 

'  Trousseau,  op.  cit.  iv.  p.  294. 

-  Tliis  iiiiiy  1)0  due  to  the  escape  of  sonic  of  flic  liqirul  contents  of  the  stic  into  the 
peritoneum,  for  the  same  symjitoin  lias  been  coiiiniunly  observed  Avlien  a  hydatid  has 
burst  into  the  peritoneal  cavity. 


LECT.  III.  HYDATID    TUMOUE.  75 

hastily  tempted  to  liave  recourse  a  second  time  to  paracentesis. 
A  certain  degree  of  fulness  may  remain  for  many  months,  or 
even  longer,  in  the  site  of  the  tumour,  the  existence  of  which 
has  been  cited  as  a  proof  that  the  operation  has  been  unsuc- 
cessful. Yet  inasmuch  as  the  operation  does  not  profess  to 
remove  the  parent  and  secondary  cysts,  but  only  to  kill  the 
hydatid,  and  thereby  avert  those  dangers  which  have  been 
shown  to  result  from  its  prolonged  vitality,  and  to  induce  that 
slow  process  of  atrophy  which  sometimes  occurs  independently  of 
an  oj^eration,  the  fulness  referred  to  is  only  what  might  be  ex- 
pected. If  by  the  operation  we  can  prevent  the  dangers  likely 
to  arise  from  a  hydatid  tumour,  nothing  more  is  necessary. 
Occasionally,  however,  the  secondary  enlargement  of  the  cyst 
does  not  subside,  and  a  fresh  puncture  becomes  necessary. 
The  fluid  obtained  by  the  second  tapj)ing  has  a  higher  specific 
gravity  than  normal  hydatid  fluid  ;  it  is  no  longer  clear  and 
free  from  albumen,  and  it  always  contains  more  or  less  pus. 
If  the  proportion  of  pus  be  small  and  the  fluid  not  fetid,  and 
if  there  be  no  severe  constitutional  symptoms,  the  first  operation 
may  be  repeated  with  a  reasonable  hope  of  success ;  otherwise 
the  case  must  be  dealt  Vv^ith  in  the  same  way  as  an  abscess,  by 
making  a  free  and  permanent  opening. 

The  safety  and  efhciency  of  the  operation  now  recommended 
may  be  regarded  as  established.  You  have  had  many  oppor- 
tunities of  satisfying  yourselves  on  this  matter  in  the  cases 
under  my  care  and  that  of  my  colleagues,  during  the  last  few 
years.  In  addition  to  the  ten  cases  which  I  have  from  time 
to  time  brought  under  your  notice  (Cases  XVI.  to  XXVI.),  I 
would  ]3articularly  direct  your  attention  to  two  which  were 
under  the  care  of  Dr.  Greenhow,  and  which  are  reported  in  the 
eighteenth  volume  of  the  '  Pathological  Transactions,'  p.  127; 
in  one  of  these  the  quantity  of  fluid  drawn  off  amounted  to  110, 
and  in  the  other  to  148  fluid  ounces ;  five  years  after  the  opera- 
tion in  the  former  case,  the  patient  was  free  from  all  signs  or 
symptoms  of  the  tumour.  These  and  many  other  similar  cases 
which  might  be  quoted  afford  the  best  answer  to  the  objection 
that  the  operation  is  only  effectual  where  the  tumour  is  small. 
It  is  true,  that  the  operation,  in  killing  the  parasite,  occa- 
sionally excites  a  certain  amount  of  inflammation  between  it 
and  the  cavity  of  the  liver  in  which  it  is  embedded,  but  in  most 
cases  this,  after  a  short  time,  spontaneously  subsides,  and  it  is 
only  in  exceptional  cases  that  a  second  operatic:!  for  the  evacua- 


^6  ENLAEGEMENTS    OF    THE    LIVER.  lect.  in. 

tion  of  pus  becomes  necessary.  I  have  collected  the  particulars 
of  103  reported  cases  in  -which  the  operation  was  performed 
(see  Tables  at  pp.  77-80) .  In  80  of  the  cases  the  operation  appears 
to  have  been  perfectly  successful :  in  sixteen  cases  it  was 
followed  by  suppuration,  and  a  free  opening  was  made  into  the 
sac,  but  all  of  the  sixteen  ultimately  made  a  good  recovery,  and 
in  several  it  appears  to  me  that  the  necessity  for  a  second 
operation  was  very  doubtful.  In  seven  of  the  cases  (Table  III.) 
the  operation  was  followed  by  a  fatal  result ;  but  in  four,  if  not 
five,  of  the  cases  death  was  due  to  causes  independent  of  the 
operation.  In  one  of  the  remaining  cases  death  was  caused  by 
sudden  collapse  twenty  minutes  after  the  puncture,  and  would 
probably  have  followed  any  operative  interference ;  only  about 
a  drachm  of  fluid  was  drawn  oif ;  no  fluid  had  escaped  into  the 
peritoneum,  and  there  was  no  sign  of  peritonitis.  In  one 
case  the  patient  died  of  peritonitis  within  twenty-four  hours  of 
the  operation,  but  he  was  in  a  state  of  extreme  prostration  and 
emaciation  before  it  was  performed,  and  thepropriety  of  having 
recourse  to  any  operative  procedure  under  the  circumstances 
may  be  doubted.  In  estimating  the  results  of  the  operation, 
those  cases  only  ought  to  be  taken  into  the  calculation  where 
it  was  resorted  to  as  a  curative  measure,  and  those  ought  to  be 
excluded  where  it  was  performed  merely  as  a  palliative,  and 
where  death  was  inevitable.  I  have  therefore  excluded  from 
the  Tables  (appended  to  this  lecture)  several  such  cases,  and 
others  where  the  operation  was  j^erformed  with  a  large  trocar, 
where  caustic  was  employed  to  procure  adhesions  before 
puncturing,  or  where  some  irritating  substance  was  injected 
after  the  Avitlidrawal  of  the  fluid,  and  also  those  where  the 
hydatid  had  suppurated  or  been  contaminated  with  bile  before 
the  oi:>eration,  and  where  a  different  mode  of  procedure  was 
advisable.  The  operation  here  recommended  is  only  adapted 
for  those  cases  where  the  fluid  retains  its  natural  limpid 
character,  and  the  results  of  other  operative  procedures  ought 
not  to  be  confounded  with  it. 


17 


Tai?le  I. — Cases  of  Hydatid  of  Liver  in  which  the  operation  of  puncture  with  a 
fine  trocar  and  closing  the  orifice  luas  followed  by  cure. 


Quantity 

No. 

Authority 

Sex 

Age 

SizG  of 
Tumour 

of  fluid 
in  ounces 
removed 

Eeforences  and  Eemarks 

1 

Murchison 

M 

28 

Moderate 

5  &20 

Case  16,  p.  87- 

2 

Do. 

F 

31 

Do. 

12 

Case  17,  p.  89. 

3 

Do. 

F 

6 

Do. 

14 

Case  18,  p.  92. 

4 

Do. 

F 

31 

Large 

20 

Case  19,  p.  93. 

6 

Do. 

P 

25 

Do. 

40 

Case  20,  p.  93. 

6 

Do. 

F 

60 

Small 

6 

Case  21,  p.  94. 

7 

Do. 

M 

8 

Do. 

6 

Case  22,  p.  94. 

8 

Do. 

M 

25 

Moderate 

8 

Case  23,  p.  95. 

9 

Do. 

M 

36 

Large 

16 

Case  24,  p.  96. 

10 

Do. 

M 

34 

Multiple 
hydatid 

4.  7,  &  U 

Case  26,  p.  99     Three  distinct 
cysts  were  tapped. 

11 

Sir  B.  Brodie 

M 

12 

Large 

30 

Med.  Chir.  Trans,  vol.  xviii. 

12 

Do. 

F 

20 

Do. 

60 

lb.  p.  119.                     [p.  118. 

13 

Do. 

M 

14 

Do. 

60 

lb.  p.  121. 

U 

Key 

F 

young 

Do. 

80 

Bright  on   Abd.    Tumours, 
Syd.  Soe.  ed.  p.  42. 

15 

Boinet 

F 

19 

Moderate 

20 

Traitement  des  Tum.  hyd.  du 
Foie,  Paris,  1859,  p.  13. 

16 

Do. 

F 

31 

Small 

4 

lb   p.  14. 

17 

Do. 

M 

20 

Moderate 

20  &  15 

lb.  p.  18.  Two  punctures  were 
made  at  an  interval  of  some 

18 

Demarquay 

M 

45 

Do. 

20 

lb.  p.  30.                       [months. 

19 

Frerichs 

M 

46 

Very  large 

120 

Dis.  of  Liver,  Syd.   Soc.  Ed. 

20 

Langenbeck 

? 

? 

? 

? 

lb.  p.  269.         [vol.  ii.  p.  268. 

21 

Do. 

? 

? 

? 

9 

lb.  p.  269. 

22 

Eecamier 

F 

young 
woman 

Moderate 

? 

Eev.  Med.  1825,  tom.  i.  p.  28. 

23 

Eobert 

M 

? 

? 

? 

Gaz.  desHopitaux,  1857,  p.  147 

24 

Do. 

F 

•? 

•? 

? 

lb.  p.  147. 

25 

Cruveilhier 

? 

? 

9 

V 

lb.  p.  147. 

26 

Kichard 

F 

42 

Large 

40 

Bull.  Gen.  de  Therap.  1855, 
p.  414.  Two  drachms  of 
alcohol  were  injected. 

27 

Greenhow 

M 

25 

Very  large 

21  &  110 

Path.  Trans,  vol  xviii.  p.  127. 
Five   years  afterwards    was 
still  in  perfect  hfalth. 

28 

Do. 

F 

30 

Do. 

148 

lb.  p.  130.  Dead  sis  years 
afterwards  from  a  return 
of  the  disease  (another  cy.st.) 

•  Path.  Trans,  vol.  xxv.  p.  130. 

29 

Duffin 

M 

27 

Moderate 

28 

Trans.  Clin.  Soc.  vol.  vi.  p.  23. 

30 

Do. 

F 

26 

Do. 

21 

lb.  p.  24. 

31 

Do, 

F 

39 

Do. 

28 

lb.  p.  27. 

32 

Do. 

M 

61 

Large 

72 

lb  p.  29.     Fluid  was  partially 

33 

Do. 

M 

50 

Do. 

64 

lb.                               [purulent. 

34 

Church 

F 

23 

Very  large 

120&114 

Treatment  of  Hyd.  Tum.  of 
Liver.  1868,  p.  15. 

35 

S.  H.  Ward 

F 

36 

Large 

37 

Some  affections  of  Liver ;  1872, 
p.  69.  More  than  a  year 
afterwards  another  tumour 
appeared,  which  ultimately 
burst  into  stomach. 

36 

Brinton 

F 

19 

Do. 

30 

Lancet,  1862,  vol.  ii.  p.  639. 

37 

J.  Hutchinson 

F 

30 

Do. 

30   ■ 

lb.  1862,  vol.  ii.  p.  389. 

78 


ENLARGEMENTS    OF    THE    LIVER. 
Table  I.  {continuecT). 


Quantity 

No. 

Authority 

Sex 

Age 

Plze  of 
Tumour 

of  fluid 
in  ounces 
removed 

References  and  Remarks 

38 

J.  Hutchinscn 

F 

33 

Large 

40 

Brit.  Med.  Journ.Feh.20,  1864. 

39 

Do. 

F 

36 

Do. 

60 

lb. 

40 

\V.  Budd 

M 

35 

Moderate 

23 

lb.  18.i9,  p.  270. 

41  I  Fearn 

M 

30 

Very  large 

85&40 

lb.  Nov.  7.  1868.  Second  punc-' 
ture,  four  months  after  first, 
broughtaway  whey-hkefluid. 

42    Hoaton 

F 

23 

Largre 

40 

lb.  Ap.  3,  1869. 

43 

Do. 

F 

20 

Small 

10 

Tb.  1874,  ii.  557.  Aspirator 
was  used  and  blood  came 
at  end  of  operation. 

44    Sympson 

M 

29 

Moderate 

16 

lb.  Ap.  30,  1870. 

45    Southey  and 

M 

24 

Very  large 

53 

lb.  Aug.  6,  1870. 

Savory 

46 

Ransom 

F 

20 

Moderate 

^ 

lb.  Sept.  28,  1872.  For  some 
days    probable     percolation 

47 

Do. 

F 

21 

Larire 

13.', 

lb.                  [into  peritoneum. 

48 

Do. 

F 

25 

V^ery  large 

33  &  72 

lb.  Second  tapping  nearly 
six  months  after  first.  Fluid 
at  first  ■  tapping  contained 
bile  and  albumen. 

49    Savory 

? 

? 

? 

? 

Church,  op.  cit.  1868,  p.  20. 

50 

Do. 

p 

? 

? 

•? 

11). 

51 

Phillipson 

M 

14 

Moderate 

23 

Brit.  Med.  Journ.  1874, ii.  557- 

52 

BradViury 

F 

23 

Do. 

16 

ib.  1874,  ii.  558. 

53 

Do. 

F 

32 

Do. 

16 

lb,  1874,  ii.  589. 

54    G.  Budd 

M 

25(?) 

Very  large 

156 

Med.  Times  and  Gaz.  Mav  19, 

55    Holthouse 

M 

56 

bo. 

100 

Ib.  Jan.  6,  1855.             [1860. 

56    Sibson 

F 

33 

Two 

50  &? 

Lancet,  July   18,    1868.     Two 

Tumours 

tumours  tapped  in  succes- 
sion,  at  an   interval   of  six 

57 

AnstiR 

F 

6 

Small 

7 

Tb.  Aug.  13,  1870.        [weeks. 

58 

Whittel 

:\i 

18 

Do. 

10 

Ib.  Oct.  15,  1870. 

59 

G.  Hett 

F 

7 

Moderate 

14 

Ib.  Feb.  18,  1871.  Doubtful 
if  cyst  in  liver.  Was  punc- 
tured below  umbilicus. 

60 

Scott  Orr 

M 

20 

Large 

46&35 

Gla.sgowMed.  .Jour.  Jan.  1876. 

6i 

McGillivray 

M 

56 

Do. 

30&20 

.\u.stralian  Med.  Journal, 
Aug.  1865.  Caseiii.  Second 
tajiping  two  weeks  after  first. 

62 

Do. 

M 

27 

? 

? 

Ib.  Case  vii. 

63 

Do. 

M 

45 

Very  large 

180&100 

Ib.  Case  xv.  -Second  tapping 
six  weeks  after  first  bri)Ught 
away  fluid  tinged  with  bile. 

64 

Do. 

F 

23 

Do. 

114 

Ib.  March,  1867.  Case  xxiv. 

65 

Do. 

^l 

5 

Three 
cysts 

20,20,10 

Ib.  Case  xxvi.  Three  dis- 
tinct cysts  were  tapped,  none 
of  which  refilled. 

66 

Do. 

M 

6 

Small 

2 

Ib.   Case  XXX vi. 

67 

Do. 

1' 

11 

Moderate 

18 

Ib.   Case  xxwii. 

68 

Do. 

.\r 

17 

Large 

70 

Ib.   Case  xxxviii. 

69 

Do. 

M 

51 

? 

9 

Ib.    July     1872.      Case     xl. 

70 

Do. 

M 

8 

? 

? 

Ib.  Ca.se  xli.       [tapped  twice. 

71 

Do. 

1' 

28 

? 

? 

Ib.  Casexlvii. 

72 

Do. 

F 

30 

9 

? 

Ib.   Cas..  hi. 

73 

Do. 

F 

44 

? 

V 

Ib.  Case  Iviii. 

74 

Do. 

M 

59 

? 

? 

Ib.  Case  lix. 

1 

HYDATID    TUMOUE. 
Tari.e  I.  {continued). 


79 


Quantity 

No. 

Authority 

Sex 

Age 

Tumour 

in  ounces 
removed 

References  and  Remarks 

75 

McGillivray 

M 

49 

? 

? 

Australian  Med.  Journ.  July 
1872.     Caselx, 

76 

Do. 

M 

32 

? 

? 

Tb.  Case  Ixvii. 

77 

Do. 

M 

3 

•? 

9 

lb.  Case  Ixx.     Tapped  twice. 

78 

Do. 

¥ 

13 

? 

9 

IIj.  Case  Ixxiii. 

i79 

Eradbury 

M 

16 

Large 

22 

Brit  Med.  .Journ.  Nov.  18,1876. 

80 

Do. 

M 

36 

Do. 

40  &  30 

lb.  Tapped  twice. 

Table  II. — Cases  of  Hydctticl  of  Liver  in  loliieh  the  operation  of  puncttcre  with 
a  fine  troca);  and  closinc/  the  orijice,  was  followed  hy  suppuration  of  the 
Sac,  a  second  free  and  permanent  opening,  and  ultimate  recovery. 


Authority 


Grarrod 
Owen  Kees 

Boinet 

Demarquay 
Babington  and 
Ccck 


T.  S}Tnpson 


Bradbury 


C.  Brook 


Duffin 


Sex 


M 


McGillivray        F 


Do. 
Do. 
Do. 
Do. 
Do. 


16    Murchison 


M 


19 
31 


50 
36 


39 

35 

23 
32 


? 

12 
13 
61 
49 

32 


Size  of 
Tumour 


Small 
Lai'ge 

Do. 

Very  large 
Large 


Do. 


Do. 


Moderate 

[cyst 
Multiple 
Moderate 


Do. 
Do. 

? 

? 

? 

Large 


Quantity 

of  fluid 

in  ounces 

removed 


4 
38 


40 


160 

10  &  8 


60  &  30 


24  &  80 


6&  12 


11 
20  &  20 


References  and  Remarks 


10 
30 

? 

? 

? 

60 


Lancet,  Sept.  1,  1860. 
Guy's  H(  sp.  Eeports,  ser.  ii. 

vol.  vi.  p.  1 7. 
Gaz.  Hebdom.  de  Med.  ser.  ii. 
1864,  i.  p.  86.  .     [p.  82. 

Gaz.  des  Hop.  Fev.  19,  18.09, 
Guy's  Hosp.  Reports,  ser.  iii. 
vol.  vi.  p.  179.     The  object 
of  the  operation  was  not  to 
remove  all  the  fluid  at  once, 
but  by  repeated  punctures. 
Brit.Med.  .Jour.  April  30, 1 870. 
Sei'ond  operation,  five  weeks 
after  first,  was  probably  un- 
necessary.    On  second  occa- 
sion   fluid   partly   fiirulent 
and  tube  was  fixed  in. 
lb.  1874,  ii.  494.     Second  ope- 
ration isix  weeks  after  first. 
Albuminuria    before     first 
puncture. 
Lancet,  1868,  vol.  i.  p.  262. 
Second  operation  was  proba- 
bly unnecessary. 
Trans.  Clin.  Soc.  vol.  vi.  p.  31. 
Australian   Med.  .J5ur.   Aug. 
186-5.     Case  xiv.    Doubtful 
if  the  cyst  which  suppurated 
was  that  wliich    bad   been 
first  tapped.     In  first  case 
cy&t  was  close  to  surface  ;  in 
second,  matter  was  3  inches 
from  s-urfacp. 
lb.  March  1867.     Case  xix. 
lb.  Case  xxxiii. 
lb.  July  1872.     Case  xxxix. 
lb.  Ca!>e  xliii. 
lb.    Case   Ii.      Tapped   three 

times  with  fine  trocar. 
Case  XXV.  p.  97. 


Ho 


ENLARGEMENTS    OF    THE    LIYEE. 


Table  III. — Cases  of  Hydatid  of  Liver  in  rohich  the  operation  of  puncture  ^vith 
a  fine  trocar,  and  closing  the  orifice,  7vas  followed  by  death. 


Aiitliority 


Molssenet 


Martineitii 


Dr.  Scott  Crr 


Bradbury 


"Wiltshire 


Murchison 


Do. 


M 


M 


M 


M 


M 


Age 


42 


31 


18 


29 


26 


21 


4.5 


12 


A  few 
grammes 


38 
Two  cysts 


Quantity 
of  fluid" 

in  ounces 
removed 


repeated 


Large 
quantity 


60 


28 


References  and  Remarks 


Arch.  Gen.  de  Med.  Fev.  1859,  p.  144. 
The  patient  was  extremely  prostrate 
before  the  operMtion.  and  died  of  peri- 
tonitis eighteen  hours  after. 

London  Med.  Record,  June  23,'  1875. 
Sudden  collapse  and  denth,  twenty 
minutes  after  operation.  Three  da,^s 
before,  severe  pain  in  epigastrium  and 
r.  hypochondrium.  No  sign  of  peri- 
tonitis at  autopsy. 

Gla.sgow  Med.  Journ.  .Jan  1876.  Pa- 
tient had  cirrhosis,  and  for  two  months 
before  operation  deep  jaundice,  and 
shortly  be'ore  operation  severe  pain 
in  tumour.  Eleven  days  after  punc- 
ture fever  set  in  and  persisted  till 
df-ath,  twenty-six  days  after  puncture. 
Two  cysts  found  after  death^one  in 
right  lobe,  which  had  be^n  tapped, 
containing  3  pints  of  j)us,  and  a  se- 
cond in  le't  lobe  containing  32^  oz. 
of  turbid  greenish  fluid. 

Brit.  Med.  Journ.  1874,  ii.  525.  Re- 
peated punctures  made  with  fine  tro- 
car. Only  about  an  ounce  of  fluid 
drawn  oif  each  time.  There  were 
three  large  cysts,  and  death  was  due 
to  one  of  them  opening  into  lung. 

Lancet.  Sept.  1,  1860.  Liver  contained 
three  other  cysts,  each  containing 
about  one  pint  of  fluid,  besides  the 
one  that  was  punctured.  Deith  ap- 
peared duo  to  the  pressure  of  the 
enormous  liver  upon  neighbouring 
organs. 

Casexxvii.p.  100.  There  were  multiple 
hydatids  of  liver  and  peritoneum,  and 
death  was  due  to  suppuration  of  a 
cyst,  distinct  Ironi  that  which  was 
punctured. 

Case  xxviii.  p.  102.  There  wore  multiple 
hydatids  of  li«er  and  prritoneum,  ami 
ascites,  &c.,  and  death  was  quite  in- 
dependent of  operation. 


LECT.  in.  HYDATID    TUMOUE.  8l 

A  careful  consideration,  then,  of  the  whole  matter — of 
the  dangers  of  the  disease  when  left  alone,  of  the  inutility  of 
medicines  on  the  one  hand,  and  of  the  success  hitherto  obtained 
from  a  simple  puncture  on  the  other,  leads  to  the  practical 
conclusion  that,  in  all  cases  where  a  hydatid  tumour  is  large 
enough  to  be  recognised  during  life  and  is  increasing  in  size, 
it  is  advisable  to  puncture  it  at  once.  If  the  tumour  appear  to 
be  diminishing  in  size,  it  maybe  well  to  wait;  but  it  is  unne- 
cessary to  wait  for  the  formation  of  adhesions,  or  to  endeavour 
to  induce  them.  A  hydatid  tumour  is  not  prone  to  form 
adhesions  over  its  outer  surface,  like  an  abscess.  By  the  time 
that  adhesions  form  in  the  natural  way,  the  tumour  has  attained 
a  large  size  and  is  probably  eating  its  way  into  some  of  the 
adjoining  cavities ;  the  chances  are  increased  of  its  becoming 
inflamed  and  converted  into  an  abscess  ;  its  walls  also  are  much 
less  elastic  than  at  an  earlier  stage,  and  a  puncture  through 
them  will  close  up  less  readily,  so  that  there  is  a  greater  risk  of 
fluid  escaping  into  the  peritoneum  after  removal  of  the  cannula 
if  there  be  no  adhesions.  While  the  walls  are  still  elastic,  the 
opening  made  by  a  fine  trocar  may  be  expected  to  close 
immediately  that  the  instrument  is  withdrawn,  and  the  exist- 
ence of  adhesions  is  therefore  unnecessary. 

4.  Evacuation  of  the  Contents  of  the  Cyst  hy  a  large  Permanent 
Opening. — In  Case  XXXII.  you  have  had  opportunities  of  study- 
ing the  dangers  to  which  a  person  must  be  subjected  who  has  a 
large  suppurating,  or  perhaps  gangrenous,  hydatid  of  the  liver 
communicating  by  a  free  opening  with  the  external  atmosphere, 
and  I  have  already  pointed  out  to  you  that  nearly  one-half  of  the 
cases  where  an  external  opening  forms  spontaneously  are  fatal. 
The  dangers  are  mainly  four;  viz.  a.  Exhaustion  from  the  pro- 
tracted discharge ;  h.  Pyaemia  and  secondary  inflammations  ; 
c.  Hsemorrhage  from  the  cavity  in  the  liver;  d.  Peritonitis. 
Of  89  cases  of  which  I  have  collected  the  particulars,  where  an 
opening  of  this  sort  occurred  spontaneously  (23  cases  and  9 
deaths)  or  was  made  by  caustic,  by  a  large  trocar,  or  by  incision, 
28  were  fatal,  or  the  mortality  was  at  the  rate  of  31*46  per 
cent.  Many  of  those  patients,  also,  who  ultimately  recovered, 
endured  a  protracted  and  exhausting  illness. 

When,  however,  the  symptoms,  or  an  exploratory  puncture, 
show  that  the  sac  has  undergone  suj)puration  and  that  its 
contents  are  fetid,  or  that  there  are  the  constitutional  sym- 
ptoms of  retained  pus,  a   large   permanent    oxDening   is    the 

G 


82  ENLARGEMENTS    OP    THE    LIVER.  lect.  in. 

only  justifiable  mode  of  operating,  and  the  operation  ought, 
if  possible,   to   be   performed   before    the  patient  has   become 
exhausted   and  cachectic   from  fever  and  retained  pus.     The 
opening  should  be  made   with   a   large   trocar,    and   a   silver 
cannula  or  india-rubber  tube  secured  in  the  wound  until  the 
whole  of  the  hydatid  contents  have  come  away.     The  cavity 
ought  to  be  washed  out  in  the  first  instance  with   a  strong 
solution    of   chloride  of   zinc   (20  grains   to   the  ounce),    and 
subsequently  at  least  once  a  day  with  an  aqueous  solution  of 
carbolic  acid  (2  per  cent.).     In  cases  where  the  operation  is 
followed  by  protracted  suppuration,  or  when  there  is  difficulty 
in  keeping  the  pus  free  from  fetor,  it  will  be  advisable  to  make 
a  counter-opening  and  introduce  a  drainage-tube,  in  the  man- 
ner recommended  by  Boinet  •  and  as  commonly  practised   in 
empyema.     Before   operating  in   this  way,  it  will   always  be 
well  to  ascertain  the  existence  of  adhesions,  and,  if  necessary, 
to  produce   them   by  an   incision   over   the   tumour   plugged 
with  lint,  by  the  application  of  caustic  potash,  or  b}'-  multi- 
plied acupuncture  with  thirty  or  forty  needles  arranged  in  a 
circle  close  to  one  another  as  practised  by  Trousseau  ;  or  an 
opening  may  be   made  by  successive    applications  of  caustic 
potash,  in  the  manner  recommended  by  Recamier  in  cases  of 
abscess.^ 

5.  Acupuncture.  A  third  plan  of  operating  on  hydatid  tumours 
remains  to  be  considered.  In  a  communication  made  to  the 
Royal  Medical  and  Chirurgical  Society  of  London  on  November 
8,  1870,  Dr.  Hilton  Fagge  and  Mr.  Durham  recorded  eight 
cases  of  hydatid  of  the  liver  treated  by  electrolysis,  in  all  of 
which  the  result  was  most  satisfactory.'  The  operation  con- 
sisted in  passing  two  electrolytic  needles  into  the  cyst  one  or  two 
inches  apart,  both  of  which  were  connected  with  the  negative 
pole  of  a  galvanic  battery  of  ten  cells.  A  moistened  sponge 
formed  the  termination  of  the  positive  pole,  and  this  was  placed 
on  the  patient's  skin  at  a  little  distance  from  the  points  of  en- 
trance of  the  needles,  and  its  position  was  changed  from  time  to 
time  during  the  operation.  The  current  was  allowed  to  pass  for 
ten  or  twenty  minutes.  In  several  of  the  cases  the  operation  was 
followed  by  the  signs  of  fluid  in  the  pleura  or  peritoneum,  so 

•  Gaz.  mid.  do  Purls,  18G0,  No.  4/5. 

•  FrericliH,  Dis.  of  Liver,  Syd.  Soc.  Ed.  ii.  p.  148. 

•  Many    years   before,   this  operation    had    been  tried  successfully  in    Iceland. 
(Frerichs,  op.  cit.  ii.  2."<1). 


HYDATID    TUMOUE. 


83 


that  there  was  reason  to  suspect  that  the  electrolysis  acted  as 
a  kind  of  subcutaneous  tapping,  with  effusion  of  the  cyst  fluid 
into  a  serous  cavity,  and  this  view  was  confirmed  by  the  fact 
that  in  one  case  equally  good  results  seemed  to  follow  the  in- 
troduction of  needles  into  the  cyst  without  the  galvanic  current. 
It  is  to  be  noted  that  the  operation  was  in  every  instance  free 
from  danger  ;  it  was  liable  to  be  followed  by  some  pyrexia  and 
temporary  refilling  of  the  sac,  but  it  did  not  set  up  active  sup- 
puration. Whether  it  be  superior  in  this  respect  to  puncture 
with  a  fine  trocar  has  yet  to  be  decided,  but  it  certainly  merits 
a  further  trial. ^ 

Note. — The  treatment  of  hydatid  tumours  advocated  in  the  above 
lecture  was  recommended  by  me,  in  a  memoir  published  in  the 
'  Edinburgh  Medical  Journal '  for  December  1865,  but  has  met  with 
opposition  from  Dr.  John  Harley,  of  London,  and  from  Dr.  Finsen,  of 
Copenhagen. 

Dr.  Harley,^  who  advocates  the  treatment  of  hydatid  tumours  of 
the  liver  by  a  large  and  permanent  opening,  gives  a  Table  of  '  84  cases 
which  were  treated  by  a  single  puncture,  evacuation  of  a  portion  or  of 
the  whole  of  the  fluid,  and  immediate  closure  of  the  wound,'  and  states 
that,  '  there  were  11  cures,  13  recoveries,  i.e.  cases  which  were  relieved 
by  the  operation,  but  which,  since  the  tumour  was  not  wholly  removed, 
or  the  result  sufficiently  certified,  cannot  be  regarded  as  radical  cures, 
and  10  deaths.'  Inasmuch  as  the  parent  and  secondary  cysts  can  never 
be  '  wholly  removed  '  by  the  operation  of  simple  puncture,  it  is  difficult 
to  understand  how  Dr.  Harley  can  admit  that  there  was  a  '  radical 
cure '  in  any  of  the  34  cases.  It  is  necessary,  therefore,  to  explain 
that  he  seems  to  look  upon  the  result  as  a  recovery,  and  not  a  ctore  if 
any  trace  of  the  tumour  can  ie  felt  some  time  after  the  operation  (as 
in  my  own  case,  No.  26  in  his  Table).  The  introduction  of  the  10  fatal 
cases  into  the  Table,  however,  throws,  in  my  opinion,  an  illegitimate 
discredit  upon  the  operation  in  question,  and  it  is,  therefore,  necessary 
to  advert  to  them  in  detail. 

Case  4. — In  this  case  the  tumour  filled  up  the  whole  abdomen  and 
the  operation  of  paracentesis  (loitJi  alargetrocar)  was  resorted  to  with 
the  object  of  relieving  the  impending  asphyxia,  and  not  as  a  cura- 
tive measure.  The  patient,  moreover,  before  the  operation,  was  in  a 
state  of  extreme  marasmus  and  prostration,  and  the  immediate  cause 
of  death  was  miliary  tubercles  in  the  lungs,  and  empyema.  See 
G-reenhow,  '  Lancet,'  1862,  ii.  p.  476,  and  Murchison, '  Ed.  Med.  Journ.' 
Dec.  1865  ;  also  Case  XXXVIII.,  p.  122  of  this  work. 

Case  8. — There  is  no  evidence  that  this  case  was  fatal.  Dr.  Harley 
quotes  the  case  from  Mr.  Caesar  Hawkins,  and  Mr.  Hawkins  fi'om  Dr. 

'  Med.  Chir.  Trans,  vol.  slix.  1866. 
G  2 


8^  ENLARGEMENTS    OP    THE    LIVER.  lkct.  ill. 

Thomas's  '  Practice  of  Physic'  Mr.  Hawkins  observes,  '  The  result  is 
not  mentioned,  so  that  it  may  probably  be  concluded  that  the  case 
ended  fatally,'  but  Dr.  Thomas  says  nothing  to  warrant  such  a  conclu- 
sion.    '  Med.  Chir.  Trans.'  vol.  xviii.  p.  121. 

(jase  9. — The  operation  was  resorted  to  merely  as  a  palliative  mea- 
sure :  8  pints  of  flu.id  were  withdrawn  from  one  cyst,  and  a  second 
cyst  containing  12  pints,  was  found  after  death  between  the  liver  and 
the  diaphragm.  Dr.  Abercrombie  adds,  '  The  two  cysts  had  so  much 
injured  the  patient's  constitution,  that,  although  he  was  relieved  by 
the  operation,  his  strength  quickly  failed  him.'  Abercrombie,  '  Dis. 
of  Stomach,'  p.  356. 

Case  10. — In  this  case  the  opening  Avas  evidently  a  large  one,  and 
it  is  not  stated  whether  it  was  closed  up  or  not.  But  what  is  more 
important,  the  hydatid  had  suppurated  before  the  operation.  Hawkins 
in  '  Med  -Chir.  Trans.'  vol.  xviii.  p.  157. 

Case  11. — From  the  original  account  of  thite  case  in  the  '  Edin.  Essays 
and  Observ.'  vol.  ii.  p.  299,  it  is  clear  that  the  boy  was  almost  moribund 
at  the  time  of  the  operation,  and  that,  in  addition  to  hydatids  of  the 
liver  and  spleen,  he  had  ascites,  general  dropsy,  and  orthopnoea.  It  seems 
probable  also  that  the  peritoneum,  and  not  the  hydatid,  was  tapped. 

Case  13. — In  this  case  there  was  great  constitutional  disturbance, 
and  the  hydatid  had  suppui^ated  before  the  operation.  The  patient 
also  was  pregnant  and  miscarried,  and  sank  after  this.  Dr.  Brighton 
'  Abdom.  Tumours,'  Syd.  Soc.  Ed.  p.  41. 

Case  15. — In  this  case  there  were  two  hydatid  tumours.  Three 
pints  of  fluid  were  drawn  from  one.  This  cyst  did  not  again  become 
enlaro-ed  and  the  patient  fancied  herself  cured,  when  death  occurred 
from  the  rupture  of  the  other  cyst  through  the  diaphragm  into  the 
lungs.     Davaine,  '  Traite  des  Entozoaires,'  p.  447. 

Case  16. — In  this  case  the  patient  was  in  a  state  of  extreme  pros- 
tration before  the  operation.  He  was  seized  with  syncope  within  five 
minutes,  and  died  at  the  end  of  eighteen  hours.  Traces  of  recent 
peritonitis  were  found  after  death.  The  fatal  result  was  no  doubt 
determined  in  this  case  by  the  operation,  but  a  large  opening  left 
patent  is  not  likely  to  have  led  to  a  more  favourable  termination. 
Table  III.,  No.  1,  p.  80  of  this  work,  and  Archiv.  Gen.  de  Med.  ser. 
V.  torn.  xiii.  p.  145. 

Case  19. — In  this  case  the  puncture  was  simply  an  exploratory  one, 
preparatory  to  the  application  of  caustic  potash  seven  days  afterwards. 
Death  was  due  io  tetanus  twenty-five  days  after  the  puncture,  and 
Recaraier  .states,  '  aucun  accident  n'a  suivi  la  ponction.'     Davaine,  op. 

cit.  p.  590. 

Case  32. — In  this  case,  according  to  Dr.  Harley,  no  attempt  was 
made  to  relieve  the  sac  of  its  contents  after  the  first  puncture,  and  the 
hvdatid  fluid  escaping  into  the  peritoneum  caused  peritonitis  and  ex- 
tension of  the  disease  ;  but  he  omits  to  mention  that  the  presence  of  a 


LBCT.  in,  HYDATID    TUMOUR.  85 

lar^e  and  increasing  amount  of  fluid  in  the  peritoneum  was  diagnosed 
before  the  operation.  Moreover,  caustic  potash  was  applied  to  the 
integuments  before  the  cyst  was  tapped.  Rogers  in  '  Brit.  Med.  Journ.' 
1862,  vol.  i.  p.  71. 

It  maj  seem  surprising  that  as  the  data  for  my  statistical 
Tables  are  in  part  derived  from  the  same  sources  as  Dr.  Harley's, 
I  should  have  been  led  to  so  diflPerent  a  conclusion.  It  is  satis- 
factory therefore  to  me  to  find  that  Dr.  Hilton  Fagge  and  Mr. 
Durham  have  taken  some  pains  to  compare  our  Tables  with  the 
original  data,  and  have  entirely  confirmed,  in  all  essential  par- 
ticulars, the  accuracy  of  my  tabular  statement.^ 

Dr.  Finsen  also  advocates  the  operation  of  Recamier — viz. 
establishing  adhesions  by  means  of  caustic,  and  then  a  free 
opening.  I  have  not  had  the  advantage  of  reading  what  he  has 
written  upon  the  subject,  but  I  am  informed  by  my  friend  Dr. 
Hjaltelin,  of  Iceland,  that  Dr.  Finsen  can  only  account  for 
my  success  with  the  simple  puncture,  on  the  supposition  that  I 
have  '  purposely  concealed  my  unsuccessful  cases.'  In  reply,  I 
have  only  to  state  that  all  the  cases  in  which  I  have  been  re- 
sponsible for  the  operation  are  appended  to  this  lecture,  and 
that  they  will  speak  for  themselves.  How  far  Dr.  Finsen  is 
competent  to  designate  the  simple  puncture  of  hydatid  tumours 
a  '  useless  and  dangerous  operation,'  I  must  leave  to  Dr. 
Hjaltelin,  physician  in  chief,  Reykjavik,  Iceland,  to  decide.  - 

On  the  other  hand,  the  success  of  the  operation  has  been 
generally  admitted  by  those  who  have  had  most  opportunities  of 
watching  its  effects.  It  is  the  treatment  commonly  practised 
in  Iceland,  where  the  disease  is  so  common.  The  following- 
passage  from  one  of  Dr.  Hjaltelin's  papers  is  worth  quoting : 
'  I  resolved  myself  to  try  the  method  of  Eecamier  in  some  cases, 
which  seemed  to  me  more  favourable  for  it  than  others,  but  am 
sorry  to  say  that  nearly  one  third  of  all  those  operated  upon  died. 
....  After  I  had  quite  given  up  the  method  of  Eecamier,  and 
had  returned  to  my  old  method  of  puncturing  hydatid  cysts,  I 
happened  to  read  Dr.  Murchison's  article  '*'  On  Hydatid  Tumours 
of  the  Liver,  their  Diagnosis  and  Treatment,  1865."  As  the  ex- 
perience of  this  physician  is  quite  in  accordance  with  my  own, 
my  faith  in  the  treatment  by  puncture  became  strengthened, 
and  I  have  since  that  time  operated  in  a  great  number  of  cases 

1  Med.  Chir.  Trans.  1871,  vol.  liv.  p.  41. 

"^  See  papers  by  Dr.  Hjaltelin,  Brit.  Med.  Journ.,  Aug.  14,  1869,  and  Edin.  Med. 
Journ.,  Feb.  1870. 


86  ENLARGEMENTS    OF   THE    LIVEE.  lect.  in. 

with  the  best  results.'  Mr.  Savory,  of  St.  Bartholomew's  Hospi- 
tal, writes  :  '  The  operation  is  7iiuch  less  likely  to  be  followed  by 
any  untoward  consequences  than  wlien  a  large  trocar  is  era- 
ployed So  convinced  am  I,  from  what  I  have  hitherto 

seen,  of  the  superiority  of  the  fine  trocar,  that  I  would  use  it 
over  and  over  again,  in  cases  where  the  cyst  refilled,  before  I 
would  employ  a  large  instrument.'^  Mr.  Durham,  of  Guy's 
Hospital,  in  the  discussion  upon  his  and  Dr.  Fagge's  paper  on  the 
treatment  of  hydatid  by  electrolysis,  stated  that  he  had  tapped 
eight  cases  by  simple  puncture  with  perfect  success. ^  Dr.  Duffin, 
of  King's  College  Hospital,  has  recorded  7  cases  of  hydatid  of  the 
liver  treated  by  simple  puncture;  all  recovered,  although  in 
two  the  sac  suppurated.^  The  treatment  by  puncture  with  a 
fine  trocar  and  cannula  was  also  strongly  advocated  by  Dr. 
W.  S.  Church  in  his  Oxford  Graduation  Essay  published  in 
1868.'*  Lastly,  in  Australia,  where  the  disease  is  very  preva- 
lent, the  operation  of  puncture  with  a  fine  trocar  is  the  treat- 
ment commonly  adopted.  Dr.  McGillivray,  among  others,  has 
pointed  out  the  superiority  of  this  plan  to  that  of  making  a  large 
and  j)ermanent  opening.  He  has  himself  operated  by  the 
former  method  in  28  cases  of  hydatid  of  the  liver,  24  of  which 
made  a  good  recovery,  although  in  6  the  sac  suppurated  (see 
Tables  I.  and  II).  Four  of  the  patients  died;  but  in  three  of 
the  four  the  operation  was  performed  merely  as  a  palliative,  and 
the  patients  were  previously  the  subjects  of  other  maladies 
(disease  of  heart  and  dropsy,  disease  of  lung  and  dropsy,  and 
diphtheria)  of  which  they  died :  in  the  fourth  case  the  fluid 
drawn  off  by  the  primary  puncture  was  '  brown  bilious-looking 
stuff,'  the  sac  suppurated,  a  lai-ge  opening  was  made,  and  the 
patient  died  from  gangrene  of  the  liver.^ 

The  records  of  the  following  cases  may  serve  to  impress 
upon  you  more  forcibly  the  symptoms  and  the  dangers  of  hy- 
datid tumours  of  the  liver,  and  their  appropriate  treatment. 
Tn  the  first  eleven  cases  (Cases  XVI.-XXVI.)  the  cyst  was 
punctured  with  a  fine  trocar,  and  after  partial  evacuation  of 
the  contents  the  opening  was  closed. 

'  Tho  Lancet,  1866,  i.  524. 

''  See  also  Mod.  Chir.  Trans,  vol.  liv.  p.  40. 

»  Trans.  Clin.  Soc,  1873,  vol.  vi.  p.  23. 

*  On  tho  Treatment  of  Hydatid  Tumours  of  tlie  Liver. 

*  Australian  Med.  Journ.,  Aug.  1865  ;  March  1867  ;  and  July  1872. 


HYDATID    TUMOUR. 


87 


Case  XVI. — Hydatid  Tumour  of  the  Liver — Paracentesis — Recovery. 

You  have  had  an  opportnmty  of  studying  the  clinical  characters  of 
hydatid  tumour  of  the  liver,  which  have  now  been  described,  in  the 
case  of  John  InT ,  aged  28,  who  was  admitted  into  Middlesex  Hos- 
pital, under  my  care,  on  Dec.  3,  1866.  He  was  a  clerk,  and  had  been 
in  the  Crimea  for  fourteen  months,  in  1855  and  1856.  His  previous 
health  had  always  been  good.  In  Sept.  1864  he  had  sore-throat  and 
slight  aching  pain  in  his  right  side,  and  it  was  then  discovered  by  Mr. 
Churton,  of  Erith,  that  he  had  a  tumour  in  epigastrium,  which  was 
almost  as  large  then  as  when  he  came  under  your  notice.  After  that 
he  suffered  no  uneasiness  in  tumour  until  Feb.  1866,  when  it  became 


Fig.  12.     Outline  of  Hepatic  Dulness  in  case  of  John  N ,  at  time  of  his  admission 

into  hospital,  Dec.  .3,  1866. 

a,  hepatic  dulness  ;  6,  tumour  ;  c,  spleen  ;  d,  heart. 

the  seat  of  occasional  darting  pains,  and  on  this  account  he  was  a  pa- 
tient in  this  hospital,  under  my  care,  from  March  31  to  April  18, 1866. 
Excepting  these  pains,  which  were  very  transient  and  unaccompanied 
by  any  tenderness,  the  patient's  general  health  was  good,  and  he  had 
not  the  slightest  fever.  On  April  7,  an  attempt  was  made  to  empty 
the  cyst  by  means  of  a  small  trocar  and  cannula  and  an  exhausting 
syringe,  the  puncture  being  made  to  the  left  of  the  middle  line,  where 
the  tumour  was  most  prominent.  The  action  of  the  syringe,  however, 
caused  much  pain  in  back  and  faintness,  and  the  operation  was  aban- 
doned after  obtaining  only  four  or  five  ounces  of  fluid,  a  quantity 
evidently  much  less  than  the  tumour  contained.  Excepting  an  attack 
of  urticaria,  the  operation  was  followed  by  no  bad  symptom. 

Patient  was  readmitted  Dec,   3,  partly  on  account  of  a  return  of 
the   slight  pain  from  which  he  had  previously  suffered,  but  mainly 


88  ENLARGEMENTS   OP   THE    LIVER.  lect.  hi. 

with  object  of  Laving  what  was  probably  a  second  cyst  emptied.     At 
time  of  readmission,  following  note  was  taken  of  his  state  : — 'Patient 
has  a  healthy  appearance,  and  his  only  complaint  is  of  a  prominent 
tnmonr  in  epigastrium,  extending  into  both  hypochondria,  and  evi- 
dently connected  with  liver.     It  fills  up  space  between  sternum  and 
umbilicus,  and  causes  a  slight  bulging  of  ribs  on  both  sides,  particu- 
larly on  the  rigM.     Its  lower  margin  is  about  one  inch  above  umbilicus. 
It  measures  about  6  inches  transversely,   and  5  inches  from  above 
downwards.       Hepatic    dulness  is    G    inches    in    mesial    line,    and    5 
inches  in  right  mammary  line  ;  in  right  axillary  and  dorsal  lines  it  is 
normal.     These  dimensions  exactly  correspond  with  those  noted  when, 
patient  left  hospital  last  April.     Upper  margin  of  hepatic  dulness  is 
not  more  arched  than  natural.     Tumour  is  globular,  perfectly  smooth, 
and  not  at  all  tender.     It  is  very  elastic,  distinctly  fluctuates,  and  pre- 
sents the  character  known  as  '  hydatid  vibration  '  in  a  marked  degree 
It  does  not  appear  to  be  adherent,  as  its  position  varies  with  respira- 
tory  movements.      No   jaundice,  no   ascites,  no  enlargement  of  the 
spleen,  and  no  albumen  in  urine.     Tongue  clean  ;  bowels  regular  ;  no 
vomiting  or  pain  after  food  ;  pulse  72.' 

On  Dec.  7,  Mr.  Moore  introduced  a  fine  trocar  into  most  prominent 
part  of  tumour,  to  right  of  middle  line,  and  drew  ofi"  by  cannula,  with- 
out any  syringe,  twenty  fluid  ounces  of  fluid.  This  fluid  was  opales- 
cent, colourless,  and  alkaline,  with  a  specific  gravity  of  1009  ;  it  con- 
tained no  albumen,  but  yielded  a  copious  white  precipitate  with  nitrate 
of  silver ;  numerous  booklets  and  several  entire  echinococci  were  dis- 
covered with  microscope.  Although  patient  had  been  taking  large 
doses  of  iodide  of  potassium  for  several  days  before  both  operations, 
on  neither  occasion  did  fluid  contain  a  trace  of  iodine. 

The  operation  was  not  followed  by  slightest  febrile  excitement  or 
unfavourable  symptom  of  any  sort.  On  Dec.  12,  patient  got  up,  and 
on  18th  he  left  hospital  apparently  well,  tumour  showing  no  tendency 
to  enlarge,  and  hepatic  dulness  in  right  mammary  line  being  only  3f 
inches. 

On  IMarch  18,  18G7,  I  again  saw  John  N ,  who  informed  me 

that  four  days  after  leaving  he  had  been  attacked  with  typhus  fever, 
which  he  had  probably  contracted  in  hospital,  and  with  which  he  had 
been  dangerously  ill.  At  commencement  of  the  fever  tumour  ap- 
peared to  enlarge,  but  by  the  time  of  his  convalescence  the  swelling 
had  quite  subsided  again,  and  now  not  the  slightest  trace  of  it  can  be 
discovered,  vertical  hepatic  dulness  in  median  line  being  only  three 
inches. 

March  9,  18G8. — Patient  presented  himself  at  hospital,  and  was 
examined  by  Dr.  H.  Thompson,  Dr.  Greenhow,  Mr.  Moore,  and  a  large 
number  of  students,  but  no  trace  of  a  tumour  could  be  discovered. 


HYDATID    TUMOUR. 


89 


Case  XVII. — Hydatid  Tumour  of  Liver,  threatening  to  hurst — Para- 
centesis— Recovery. 

On  Aug.  3,  1864,  Hannali  S ,  a  very  nervous  woman,  aged  31, 

consulted  me  about  a  tumour  in  region  of  liver.  She  was  a  cook  in  a 
medical  man's  family.  In  summer  of  1863  she  had  been  laid  up  for 
three  weeks  with  a  pain  across  stomach ;  but,  with  this  exception,  she 
had  never  suffered  from  any  symptom  of  abdominal  disease  until  about 
nine  weeks  before  she  came  to  me.  She  was  then  seized  suddenly 
with  acute  pain  in  region  of  liver,  which  lasted  about  two  hours.  For 
several  days  she  vomited  everything  she  ate,  and  she  had  great  pain  in 
right  side  when  she  attempted  to  cough  or  to  turn  in  bed.  She  kept 
her  bed  for  a  week,  and  did  not  resume  her  work  for  three  weeks. 


Fig.  13  represents  the  outline  of  Hepatic  Dulness  in  the  case  of  Hannah  S ,  in 

August  1864. 

a,  tumour  ;  6,  spleen  ;  c,  heart. 


Liver  was  then  first  observed  to  be  enlarged  and  prominent,  but  pa- 
tient was  unable  to  say  whether  this  enlargement  had  existed  before 
attack  of  pain  or  not.  On  examination,  a  slight  bulging  was  found  in 
right  hypochondrium  below  ribs,  this  bulging  being  apparently  con- 
tinuous above  with  liver,  extending  to  half  an  inch  below  umbilicus, 
and,  transversely,  from  one  inch  to  left  of  mesial  line  to  about 
3  in.  to  right.  Vertical  hepatic  dulness  two  inches  within  right 
nipple  was  7  in.,  4^  in,  of  the  dull  space  being  below  edge  of  ribs. 
Tumour  was  tense,  bnt  elastic,  and  almost  fluctuating.  It  was  slightly 
tender  on  deep  pressure.  It  did  not  appear  to  be  adherent  to 
abdominal  wall.  Posteriorly,  hepatic  dulness  did  not  extend  too  high 
and  upper  margin  not  preternaturally  arched.     Respiratory   sounds 


90  ENLAEGEMENTS    OF    THE    LIVER.  lect.  in. 

at  right  base  were  normal.  Patient  -was  slightly  sallow,  but  had  no 
decided  jaundice.  Tongue  clean  ;  appetite  good  ;  bowels  regular.  No 
ascites  and  no  anasarca  ;  urine  contained  neither  albumen  nor  bile- 
pigment.  Pulse  84. 

On  Aug.  7  patient  had  a  return  of  pain  in  tumour,  accompanied 
by  vomiting  and  purging,  lasting  for  two  or  three  days.  For  several 
days  after  this  attack  tumour  was  tender,  and  over  its  surface  coarse 
friction  could  be  both  heard  and  felt  during  respiratory  movements. 

On    Aug.   19  Hannah   S was   admitted,   under  my  care,  into 

]\Iiddlesex  Hospital,  and  placed  on  iodide  of  potassium,  five  grains 
three  times  a  day. 

On  Aug.  2-i  tumour  was  noted  as  more  tense  and  tender.  On 
night  of  Sept.  2  patient  had  an  attack  of  acute  pain  in  right  side, 
greatly  increased  by  pressure,  movement,  or  a  long  inspiration,  and 
accompanied  by  much  nausea,  but  by  no  vomiting  or  rigors  Pulse 
06.  Under  use  of  opium,  poultices,  and  rest,  these  symptoms  gradually 
subsided,  but  tumour  continued  tender,  friction  was  again  distinguish- 
able for  several  days,  and  pulse  did  not  fall  beloAv  96.  On  Sept.  9 
patient  had  another  similar  attack  of  pain,  but  more  severe  ;  pulse  rose 
to  116,  and  friction  returned.  On  Sept.  14  pain  was  less,  but  tumour 
was  observed  to  extend  more  to  right  side,  and  was  less  rounded. 
On  Sept.  17  another  severe  attack  of  pain ;  and  indeed,  since  Aug.  24, 
tumour  had  never  been  free  from  tenderness,  while  patient  felt  herself 
gradually  getting  weaker,  pulse  being  rarely  beloAv  108. 

Although  there  was  no  evidence  of  firm  adhesions  over  tumour,  it 
was  now  determined  to  puncture  it.  From  first,  tumour  had  been 
diagnosed  as  a  hydatid,  and  indeed  the  object  of  patient's  admission 
into  hospital  was  to  have  it  punctured.  All  Avho  examined  it  were 
agreed  that  it  contained  fluid,  and  the  only  other  aSections  at  all  likely 
to  produce  appeai'ances  observed  were  a  distended  gall-bladder  and  an 
abscess  of  liver.  The  tumour  did  not  occupy  quite  the  situation,  and 
latterly  did  not  present  shape  of  a  distended  gall-bladder,  and  there 
had  never  been  jaundice.  The  persistent  pain  and  tenderness  noted 
for  several  weeks  pointed  rather  to  abscess,  but  there  had  been  no 
rigors  or  perspirations,  and,  moreover,  the  tumour  had  not  increased 
much  in  size  since  it  had  been  first  observed.  Supposing  the  tumour 
to  be  hydatid  there  was  reason  to  fear  that  it  was  about  to  burst. 

On  Sept.  20  Mr.  Hulke  tapped  tumour  with  a  fine  trocar,  the 
cannula  of  which  was  scarcely  so  large  as  a  No.  1  catheter,  and  drew 
off  about  twelve  fluid  ounces  of  clear  limpid  fluid,  specific  gravity  of 
which  was  1009.  No  echinococci  or  booklets  could  be  discovered  in  it, 
but  it  was  found  to  contain  a  larcre  amount  of  chloride  of  sodium  and 
no  albumen.  It  did  not  contain  a  trace  of  iodine,  although  iodide  of 
potassium  had  been  taken  almost  continuously  for  several  weeks. 

In  removing  cannula,  abdominal  parietes  were  pressed  down  against 
tumour,  and  puncture  was  afterwards  covered  with  collodion  and  a 


M5CT.  III.  HYDATID    TUMOUR.  9 1 

pad.  Patient  was  kept  on  her  back  for  forty-eiglit  hours,  and  not  per- 
mitted to  move.  Twenty  drops  of  laudanum  were  administered  im- 
mediately after  operation,  and  for  two  days  an  opiate  was  given  about 
once  in  four  or  six  hours. 

The  night  after  the  operation,  patient  slept  well.  On  following  day, 
urine  was  retained,  and  was  drawn  ofl'  by  catheter ;  and  on  Sept.  22 
abdomen  was  distended  and  tympanitic,  skin  hot  and  dry  (temperature 
101°),  pulse  120,  and  much  thirst.  Still  there  was  much  less  pain  and 
tenderness  over  tumour  than  before  operation.  Bowels  had  not  been 
open  for  two  days.  An  enema  of  turpentine  and  confection  of  rue 
brought  away  a  large  quantity  of  flatus,  and  patient  at  once  began  to 
improve.  On  Sept.  26,  pulse  96,  tongue  clean  and  moist,  and  appetite 
returning.  For  first  time  for  several  weeks',  patient  could  tolerate  free 
manipulation  of  tumour,  dimensions  of  which  were  much  reduced. 
On  Sept.  27,  pulse  84  ;  collodion  was  removed  from  wound,  from  which 
not  a  drop  of  discharge  had  escaped.  On  Sept.  30  patient  was  able  to 
get  up.  Convalescence  was  retarded  by  an  attack  of  facial  neuralgia 
and  other  trifling  ailments ;  but  on  JSTov.  22,  patient  was  able  to  leave 
hospital.  Dimensions  of  tumour  were  gradually  diminishing,  so  that 
dulness  from  upper  margin  of  liver  to  lower  margin  of  tumour  did  not 
exceed  5|  inches.  Tumour  also  was  quite  soft  and  free  from  tension, 
and  could  be  manipulated  without  causing  pain.  Tongue  clean  and 
moist ;  appetite  and  digestion  good.     Pulse  100. 

June  3867. — Nearly  three  years  have  now  elapsed  since  operation, 
and  during  most  of  that  time  patient  has  been  able  to  follow  her  occupa- 
tion as  a  cook,  subject  -only  to  flatulence  and  other  symptoms  of  dyspepsia 
and  hysteria.     Only  a  slight  fulness  is  now  perceptible  in  epigastrium. 

Early  in  1868,  patient  wrote  that  she  was  quite  well  and  was  about 
to  be  married.  In  autumn  of  that  year  she  had  a  child,  who  died  soon 
after  birth.  After  this  she  fell  into  low  spirits,  and  she  was  again 
under  my  care  in  Middlesex  Hosp.  during  Jan.  1868.  She  was  then 
suff'ering  from  dyspepsia,  flatulence,  and  hysterical  pains.  A  hard 
mass  about  size  of  an  orange  could  still  be  felt  in  site  of  tumour  ;  it 
was  quite  painless,  and  did  not  seem  to  be  connected  with  patient's 
symptoms. 

July  1873. — Patient  wrote  to  say  that  she  was  much  in  same  con- 
dition and  that  tumour  was  no  larger. 

Case  XVIII.  was  remarkable  for  the  early  age  of  the 
patient.'  Trousseau  has  recorded  a  case  where  the  patient  was 
also  only  six,  and  adds  that  Davaine,  in  his  great  work  on 
Entozoa,  had  not  been  able  to  collect  more  than  14  cases  in 
subjects  under  fifteen  years  of  age ;  but  in  one  of  Davaine's 
cases  which  he  quotes  from  Cruveilhier,  the  subject  was  a  child 

>  Clin.  Med.,  Syd.  Soc.  Trans,  iv.  26i. 


92  ENLAEGEMENTS   OF    THE    LIVER.  lect.  hi. 

only  twelve  dai/s  old,  and  the  cyst  had  already  opened  into  the 
descending  colon.    (See  also  Case  XXIT.  and  Tables  I.  and  II.) 

Case  XVIII. — Hydatid  Tumour  of  Liver — Puncture  with  fine  Trocar — 

Hecoverij. 

Elizabetli  C ,  aged  6,  adm.  into  Middlesex  Hosp.  under  my  care 

Dec.  3,  1867.  With  exception  of  whooping-cough  at  age  of  3,  she  had 
always  enjoyed  excellent  health  ;  but  her  niother,  almost  since  she  was 
an  infant,  had  noticed  that  she  was  larger  about  the  waist  than  natural. 
Three  months  before,  the  girl  had  been  seen  by  Miss  Garrett,  M.D., 
who  diagnosed  hydatid  of  liver.  Since  then  mother  thinks  that  tumour 
has  been  increasing,  but  the  only  uneasiness  child  has  experienced  has 
been  an  occasional  feeling  of  sickness,  a  morning  cough,  and  slight 
pain  in  region  of  liver.  On  admission,  patient  was  a  robust,  healthy, 
looking  child,  who  seemed  to  have  nothing  amiss  with  her,  with  ex- 
ception of  a  swelling  in  epigastrium,  extending  vertically  from  loAver 
end  of  sternum  to  umbilicus,  and  2\  inches  laterally  to  either  side  of 
mesial  line.  The  tumour  was  globular,  smooth,  painless  on  manipu- 
lation, and  with  distinct  fluctuation,  and  ■■  hydatid  vibi'ation.'  It  was 
quite  movable  over  subjacent  parts,  and  did  not  appear  to  be  adherent 
to  abdominal  parietes,  as  it  descended  readily  with  inspiration.  Al- 
though evidently  connected  with  liver,  area  of  hepatic  dulness  was 
not  generally  inci'eased,  its  extent  in  right  mammary  line  measuring 
only  2^  inches.     Girth  of  abdomen  over  tumour  was  as  follows  : 

At  umliilicus 

At  eiisifurm  cartilage     . 

Ualf-way  between  umbilicus        [^S-TS  24-66  25-25  24-  22-5 

and  ensiform  cartilage        .      ) 

Tongue  clean,  appetite  good,  bowels  regular.  There  was  neither 
ascites  nor  jaundice.  Pulse  96.  She  was  ordered  a  draught  containing 
two  grains  of  iodide  of  potassium  three  times  a  day. 

On  Dec.  10  Mr.  Hulke  punctured  tumour  with  a  fine  trocar,  and 
drew  ofi'  fourteen  fluid  ounces  of  fluid.  This  was  colourless,  slightly 
opalescent,  with  a  specific  gravity  of  1010,  and  contained  no  albumen, 
but  a  large  quantity  of  chlorides  ;  neither  echinococci,  nor  booklets, 
nor  any  trace  of  iodine  could  be  detected  in  it.  Two  hours  after  opei-a- 
tion  patient  Avas  sitting  up  in  bed  laughing  and  talking  as  if  nothing 
had  happened.  During  following  night,  however,  she  had  several 
attacks  of  vomiting  (whicli  was,  perhaps,  the  effect  of  chloroform  that 
had  been  administered),  and  for  two  days  the  pulse  rose  to  14-0,  and  the 
temperature  was  as  high  as  1008°  ;  but  there  was  no  tenderness  of 
abdomen,  nor  thoracic  breathing. 

On  Dec.  13  temperature  and  pnlse  were  again  normal,  and  after 
this  patient  had  no  bad  symptom,  except  that  from  Dec.  20  till  Jan.  14 
tumour  appeared  to  increase  again  slowly  in  size,  so  that  the  question 


Dec.  3. 

Dec.  20. 

Jan.  16. 

Jan.  24. 

:March  9. 

24-3 

23-3 

24-5 

22-75 

22-0 

24-5 

23-5 

23-5 

23-75 

23-5 

LECT.  111.  HYDATID    TUMOUE.  93 

of  performing  paracentesis  a  second  time  was  entertained.  Tliis,  how- 
ever, was  abandoned,  for  tumour  began  to  diminish  spontaneously,  as 
will  appear  from  table  of  measurements.  On  March  9  there  was  no 
perceptible  bulging  and  scarcely  any  tumour  to  be  felt. 

Case  XIX. — Hydatid  Tumour  of  Left  Lohe  of  Liver — Paracentesis — 

Becovery. 

Emma  H ,  aged  31,  adm.  into  Middlesex  Hosp.  Dec.  4,  1868. 

Married  and  had  five  children  ;  youngest  child  born  sixteen  months  be- 
fore had  survived  birth  only  three  days.  After  this  suffered  from  languor, 
prostration,  and  low  spirits,  and  while  in  this  state  attention,  was  first 
drawn  by  a  feeling  of  heat  to  a  swelling  in  left  hypochondrium,  which, 
however,  had  not  materially  increased  in  size  since  it  had  been  first 
noticed ;  nor  had  it  prevented  her  following  her  ordinary  household 
occupations.  On  admission,  there  was  a  tumour  filling  epigas- 
trium, extending  to  2^  in.  below  umbilicus,  measuring  7-^  in.  verti- 
cally, and  10  in.  transversely,  bulging  forwards,  tense,  smooth,  fluc- 
tuating, with  distinct  '  hj^datid  vibration,'  and  slightly  tender.  The 
tumour  evidently  grew  downwards  from  liver,  which  did  not  extend 
too  high  upwards  ;  it  did  not  appear  to  be  adherent  to  abdominal  wall. 
The  patient  was  anaemic,  but  her  general  health  was  in  other  respects 
good.  Dec.  6,  ordered  5  grains  of  iodide  of  potassium  three  times  a 
day.  Dec.  10,  paracentesis  with  fine  trocar  :  one  pint  of  fluid  drawn 
off,  limpid,  sp.  gr.  1009,  and  containing  much  chlorides,  but  not  a 
trace  of  albumen  or  of  iodine  ;  last  few  ounces  had  a  sp.  gr.  of  1012 
and  contained  blood -and  bile-pigment.  No  bad  symptom  followed 
operation  ;  pulse  never  exceeded  80,  and  skin  was  cool.  On  Dec.  18 
patient  got  up,  and  on  28th  she  left  hospital. 

July  19,  1872.  Patient  called  at  my  house.  Has  had  two  children 
since  operation,  and  is  now  suckling  second,  aged  12  months.  A  small 
hard,  non-elastic,  painless  tumour  can  still  be  felt  in.  epigastrium,  but 
this  is  the  source  of  no  inconvenience. 

Case  XX.—  Hydatid  of  Left  Lobe  of  Liver — Paracentesis — Becovery. 

Mrs.  R ,  aged  25,  consulted  me  on  Dec.  29,  1871,  on  account  of 

a  smooth  painless  tumour  in  hypochondrium,  apparently  gi'owing  from 
left  lobe  of  liver,  and  reaching  down  to  umbilicus,  which  had  been 
first  noticed  two  years  before  and  which  had  since  slowly  increased. 
Girth  over  most  prominent  part  of  tumour  29^  in.  :  right  side,  14  in.  ; 
left,  15;^.  Chief  complaint  was  of  constant  pain  in  back,  and  atonic 
dyspepsia.  Improvement  took  place  under  use  of  nitro-muriatic  acid 
and  strychnia  ;  and  on  March  5,  1873,  patient  was  stouter  and  stronger, 
but  tumour  was  larger  ;  girth  on  left  side  over  tumour  16  in. ;  right 
side,  14  in.  March  24.  Paracentesis  with  fine  trocar.  Drew  off'  40 
fluid  ounces  of  limpid  fluid,  containing  much  chlorides  but  no  albumen ; 


94  ENLARGEMENTS    OF    THE    LIVER.  lect.  hi. 

sp.  gr.  1010.  March  25,  no  pain;  pulse  74;  temp.  98'4°.  March  27, 
pulse  96  ;  temp.  102'5°.  March  31.  Up  and  going  about,  but  tumour 
appears  to  be  sligbtly  larger  again  ;  pulse  84  ;  temp.  101*5°.  Ap-'d  7. 
Tumour  smaller  again,  and  has  got  on  stays  first  time  for  years.  Less 
pain  in  back  than  she  has  had  for  a  long  time.  Pulse  90  ;  temp.  101°. 
May  7.  Much  better,  and  gained  flesh.  Girth  equal  on  two  sides  ; 
viz.  14^  in. 

July  1875.  Patient  is  in  enjoyment  of  excellent  health,  and  there 
is  no  sign  of  tumour. 

Case  XXI. — Hydatid  of  Rigid  Lobe  of  Liver — Neuralgic  Pain — 
Paracentesis — Recovery . 

On  Oct.  30,  1873,  I  saw  in  consultation  with  Mr.  R.  Phillips,  of 

Leinster  Square,  a  lady,  Mrs.  M ,  aged  sixty,  who  had  a  large  smooth 

tumour  in  right  hypochondrium,  connected  with  liver.  Hepatic  dul- 
ness  in  front  arched  up  to  nipple,  measured  8  in.  in  right  nipple  line, 
bat  did  not  ascend  too  high  at  back.  Lower  margin  of  right  lobe  de- 
scended to  level  of  umbilicus.  Lower  right  ribs  and  cartilages  formed 
a  visible  bulging  forwards  ;  girth  over  most  prominent  part  from  spine 
to  middle  line  in  front  17  in.,  and  at  corresponding  part  of  left  side 
ISj-  in.  Over  most  prominent  part  ©f  swelling  between  ribs,  as  well 
as  below  them,  decided  elasticity  and  even  obscure  fluctuation  ;  no 
tenderness.  Tumour  had  been  first  observed  ten  months  before,  and 
had  not  materially  increased.  Ever  since  she  had  been  liable  to  severe 
neuralgic  pains,  and  a  disagreeable  feeling  of  tightness  about  liver ; 
and  four  months  after  she  became  aware  of  tumour  she  had  an  attack 
of  pleurisy  on  right  side  with  effusion,  which  had  been  absorbed.  Her 
only  other  symptoms  were  some  nausea  and  loss  of  appetite. 

I  advised  a  puncture  with  a  fine  trocar  between  the  ribs,  and  a  few 
days  afterwards  Mr,  Phillips  drew  off  from  swelling  by  aspirator  six 
ounces  of  fluid.  This  was  faintly  opalescent,  had  sp.  gr.  of  1010,  was 
unchanged  by  boiling,  but  became  slightly  opaque  on  adding  nitric 
acid,  formed  a  dense  white  deposit  with  nitrate  of  silver,  and  contained 
numerous  echinococci.  The  tightness  and  neuralgic  pains  were  at 
once  relieved,  and  lower  mai'gin  of  liver  receded  almost  to  margin  of 
ribs.  No  bad  symptom  followed,  and  in  July  1875  patient  was  in 
good  health,  and  had  no  sign  of  tumour.  Oct.  1876.  Still  in  good 
health.     No  pain,  or  swelling. 

Case  XXII. — Hydatid  Tumour  bulging  from  upper  surface  of  Liver, 
and  pressing  it  down — Paracentesis — Recovery, 

Albert  D ,  aged  8,  a  pale  rather  thin  boy,  was  brought  to  St. 

Thomas's  Hosp.  Jan.  1,  1874,  on  account  of  a  swelling  in  upper  part 
of  abdomen,  which  had  been  first  noticed  between  two  and  three  years 
before,  and  which  had  slowly  increased  in  size,  without  pain  or  other 
uneasiness.     The  swelling  extended  from  ribs  to  1  ^  in.  below  umbi- 


i-ECT.  in.  HYDATID    TUMOUR.  95 

licus.  Its  surface  was  marked  by  a  transverse  furrow,  3  in.  above 
umbilicus.  Below  this  its  consistence  was  firm,  and  what  was 
felt  appeared  to  be  the  liver ;  while  between  furrow  and  ribs  was  a 
globular  prominence,  smooth,  painless,  fluctuating,  and  yielding  dis- 
tinct '  hydatid  vibration  '  on  percussion.  There  was  dulness  over  right 
lower  ribs,  rising  to  about  level  of  normal  hepatic  dulness,  but  its 
upper  margin  was  too  much  arched.  Hepatic  dulness  in  r.  m.  1.,  in- 
cluding liver,  9^  in.  ;  girth  of  abdomen  round  most  prominent  part  of 
tumour  25  in.  ;  from  ensiform  cartilage  to  umbilicus  7  in. ;  from  um- 
bilicus to  pubes  4^  in.  Pulse  84 ;  apex  of  heart  elevated,  beating  be- 
tween third  and  fourth  ribs.  Tongue  clean  ;  appetite  good ;  bowels 
regular  ;  no  jaundice  ;  no  pain  ;  no  ascites  or  cedema  of  legs. 

Ordered  Fer,  et  quin.  cit.  gr.  iij  t.  d.  s. 

Jan.  8.  Paracentesis  at  10  a.m.  with  fine  trocar ;  6  ounces  of  clear 
fluid  drawn  off,  containing  much  chlorides,  but  no  albumen  ;  sp.  gr.  1011. 
The  operation  was  followed  by  no  pain  or  uneasiness,  but  temperature 
same  evening  rose  to  102'8°,  and  on  the  three  successive  nights  it  was 
103-1°,  101-8°,  and  101-5°.  On  morning  of  9th  it  was  101-2°,  but  on 
other  mornings  it  was  normal.  During  night  of  9th  patient  was  some- 
what restless  and  thirsty,  but  by  12th  fever  had  subsided,  and  wben 
patient  left  hospital  on  22nd  girth  over  most  prominent  part  of  tu- 
moiir  was  24^  in.,  and  swelling  was  much  less  prominent  and  tense,  but 
to  right  of  cyst  wMch  had  been  tapped  appeared  to  be  a  second,  in 
which,  however,  fluctuation  was  not  very  distinct.  This  was  not  inter- 
fered with. 

Case  XXIII. — Hydatid  of  Liver  commencing  to  suppurate — Paracentesis 

— Recovery. 

On  March.  11,  1876,  I  saw,  in  consultation  with  Dr.  Barker,  of 
Hornsey,  Mr.  P ,  aged  25,  who  had  a  tumour,  presenting  all  cha- 
racters of  hydatid,  projecting  downwards  from  right  lobe  of  liver.  It 
formed  a  distinct  prominence,  whicli  measured  7^  in.  both  verti- 
cally and  transversely.  It  had  been  discovered  about  previous  Christ- 
mas, when  it  first  became  seat  of  slight  pain.  Since  first  noticed  it 
had  increased  unmistakably,  but  not  greatly.  I  tapped  it  with  a  fine 
trocar,  and  drew  off  eight  ounces  of  thin  fluid,  which  was  turbid,  of 
1010  sp.  gr.,  contained  much  chlorides  and  a  little  albumen,  and  threw 
down  a  creamy  deposit  made  up  of  pus,  oil,  cholesterin,  booklets,  and 
shreds  of  hydatid  membrane. 

April  25. — For  three  or  four  days  after  puncture,  much  pain  and 
sickness,  but  all  subsided  under  opium  and  efiervescing  draughts.  At 
end  of  two  weeks  tumour  much  smaller,  but  in  last  fortnight  has  been 
enlarging  again,  and  now  measures  6  in.  vertically  and  7-|-  in.  trans- 
versely.    General  health  good. 

June  8. — Gained  flesh  and  colour,  and  tumour  much  smaller,  mea- 
sures 4^  in.  vertically,  and  5^  in.  transversely. 


96  ENLARGEMENTS    OF    THE    LIVER.  lect.  hi. 

Oct.  3. — Much  stouter,  and  general  liealth  excellent.  Has  no  dis- 
comfort from  tumour,  which  continues  to  get  smaller,  and  feels  much 
harder. 

Case  XXIV. — Hydatid  of  Liver — Paracentesis — Becoverjj. 

Deacon  B.,  aged  36,  railway  station-master,  adm.  into  St.  Thomas's 
Hosp.  June  1,  1876.  Tertian  ague  at  18,  in  Cambridgeshire.  Except- 
ing this,  health  had  been  good.  For  eight  yeai^s  had  complained  of  a 
feeling  of  weight  and  occasional  slight  pain  in  region  of  liver;  six 
months  ago  these  symptoms  attracted  more  attention,  and  three  months 
ago  first  noticed  a  swelling  which  had  slowly  increased  in  size.  Six 
weeks  ago  had  an  attack  of  acute  pain  in  tumour,  subsiding  in  24  hours, 
but  leaving  him  weak,  so  that  he  kept  his  bed  for  a  fortnight.  Lost 
about  a  stone  in  weight,  but  regained  it  before  admission. 

On  admission,  a  distinct  prominence  between  costal  cartilages  and 
umbilicus,  more  on  right  side  than  left,  evidently  due  to  a  growth  from 
liver,  smooth,  rounded,  painless,  tense  but  elastic ;  no  thrill  or  vibra- 
tion ;  its  lower  margin  reaching  to  umbilicus.  Liver  generally  not 
enlarged;  upper  margin  not  too  high  ;  dulness  in  r,  m.  1.  7  in.,  in 
mesial  line  9  in. ;  girth  of  abdomen  over  tumour  36 j  in.  Body  well 
nourished ;  no  pyrexia  or  perspiration  ;  appetite  good,  and  sleeps  well. 
Chief  inconvenience  from  swelling  is  some  dyspnoea  on  exertion, 
and  a  feeling  of  tightness  after  food  or  when  he  stoops. 

June  5. — Paracentesis  with  fine  trocar ;  16  ounces  of  clear  fluid 
drawn  off;  sp.  gr.  1009  :  abundant  chlorides  ;  not  a  trace  of  albumen, 
even  with  cold  nitric  acid  test. 

June  17. — Got  up  after  two  days,  and  has  not  had  a  bad  symptom. 
Temp,  on  night  of  June  7  rose  to  100'8°,  but  with  this  exception  has 
been  normal  throughout.  No  pain  ;  no  urticaria.  No  evidence  of  cyst 
refilling ;  lower  margin  2^  in.  above  umbilicus  ;  girth  over  its  most 
prominent  part  35  in.,  same  as  day  after  tapping. 

July  15. — Came  to  show  himself  at  hospital.  Has  had  flatulence 
and  uneasiness  about  tumour,  but  this  has  not  increased  in  size ;  girth 
over  it  still  35  in.,  but  patient  has  got  stouter. 

Oct.  20. — Examined  him  again.  Tumour  imperceptible,  and  ex- 
cepting flatulent  dyspepsia  general  health  good.  Has  followed  em- 
ployment for  last  three  months. 

In  Case  XXV.  the  operation  of  simple  puncture  was  followed 
by  suppuration  of  the  sac,  with  much  fever,  and  it  was  neces- 
sary to  make  a  free  openinj^.  It  is  to  be  noted,  however,  that 
before  the  operation  the  patient  had  symptoms  of  congestion  of 
the  liver,  and  that  the  immediate  cause  of  the  severe  inflamma- 
tion of  the  sac  was  a  chill.  The  case  further  illustrates  the 
good  effects  of  antiseptic  treatment  in  dealing  with  alarge  abscess 
of  the  liver,  full  of  fetid  pus. 


LECT.  in.  HYDATID    TUMOUR.  97 

Case  XXV. — Hyilatld  of  Liver — Paracentesis — Suppuration — Free 
Opening — liecovery. 

Hannah  B ,  aged  32,  adm.  into  Middlesex  Hosp.  Nov.  30,  1869. 

In  Kov.  1866  began  to  suffer  from  occasional  pain,  not  severe,  in  right 
side.  In  N'ov.  1868  first  noticed  a  fulness  in  right  side,  which  has  con- 
tinued to  increase.  One  month  before  admission  lost  appetite,  began 
to  suffer  from  nausea,  vomited  bile  occasionally,  and  became  slightly 
jaundiced  (hepatic  congestion).  On  admission,  liver  greatly  enlarged, 
extending  in  front  from  upper  border  of  fourth  rib  to  2  in.  below 
umbilicus  ;  measurement  in  r.  m.  1.  12  in.  and  in  mesial  line  11  in. 
Posteriorly,  upper  margin  of  hepatic  dulness  not  higher  than  natural. 
Girth  over  most  prominent  part  of  tumour  one  inch  below  lower  end  of 
sternum,  right  side  \Q\  in.,  left  15;^  in.  Surface  of  tumour  below 
ribs  smooth,  elastic,  painless,  except  close  to  ribs,  where  it  is  slightly 
tender  and  distinctly  fluctuating,  but  no  '  vibration.'  Slight  jaundice. 
Urine  contains  same  bile-pigment,  but  no  albumen  ;  motions  contain 
bile. 

Dec.  9. — Jaundice  and  dyspeptic  symptoms  have  almost  disappeared, 
but  urine  still  contains  bile.  Cyst  tapped  with  fine  trocar,  and  60 
ounces  of  alkaline  limpid  fluid  drawn  off,  containing  much  chlorides, 
but  no  albumen  ;  sp.  gr.  1009  :  no  echinococci  or  booklets  found.  On 
evening  of  same  day  felt  chilly ;  pulse  102  ;  temp.  102-2°  :  but  no  pain. 
After  24  hours  the  febrile  symptoms  subsided,  and  patient  felt  more 
comfortable  than  before  operation,  but  the  urine  still  contained  bile. 
On  Dec.  16  she  got  up. 

Dec.  22. — On  evening  of  Dec.  20  had  headache,  but  yesterday  was 
up  all  day  and  went  down  to  Board  Room  to  pass  for  discharge,  when 
she  fancied  that  she  caught  cold.  Last  night  she  began  to  suffer  from 
thirst,  and  to-day  pulse  120  :  temp.  103"8°.  No  rigors,  but  felt  chilly 
this  morning  ;  no  abdominal  pain.  Next  night  she  had  no  sleep,  per- 
spired profusely,  and  had  frequent  retching.  On  Dec.  23  she  had  slight 
pain  in  region  of  tumour  on  taking  a  deep  breath  ;  pulse  118  ;  temp. 
101  "4°.  In  the  evening  she  had  a  severe  rigor  followed  by  perspira- 
tions. 

Dec.  24. — Jaundice  increased.  Urine  contains  a  trace  of  albumen 
and  much  lithates.     Pulse  110  :  temp.  104"4°. 

Jan.  1. — Still  very  ill.  Pulse  has  varied  from  106  to  120,  and  temp, 
from  101*2°  to  105°.  No  return  of  rigors,  but  perspires  freely  at  night. 
Urine  always  contains  albumen  (^V)-  Occasional  retching  and  jaun- 
dice continue.  For  several  days  has  had  frequent  cough,  and  to-day 
there  are  coarse  moist  sounds  over  lower  two-thirds  of  both  lungs  at 
back,  and  sibilant  rales  in  front.  Tumour  is  evidently  enlarging  again. 
Sleeps  little. 

Jan.  10. — Early  this  morning  had  a  second  slight  rigor  followed  by 
perspiration,  but  is  on  the  whole  better.     Temperature  for  several  days 

H 


q8  enlargements    op    the    LIVEE.  lect.  m. 

has  "been  falling  and  is  now  normal.    Less  jaundice.  Urine  still  contains 
albumen.     Still  much  congestion  of  lungs. 

Jan.  26. — General  condition  much  improved.  Temp.  98°,  and  has 
rarely  exceeded  100°.  Cough  much  less,  breathing  easier;  very  few- 
rales  in  lungs.  No  albumen  in  urine.  For  two  days  has  had  rather 
severe  pain  in  tumour,  which  continues  to  enlarge. 

Feb.  2. — Pain  continues,  and  pyrexia  has  increased,  temp,  varying 
from  98°  to  101'8°.  Pulmonary  congestion  increased.  Girth  half- 
way between  sternum  and  umbilicus  is  now  37  in.  No  albumen  in 
urine.  About  a  pint  of  thin  fetid  pus  was  drawn  off  from  tumour 
by  a  small  trocar,  and  a  piece  of  Vienna  paste  about  size  of  shilling  was 
on  Feb.  3  applied  at  spot  where  puncture  had  been  made. 

Feb.  6. — An  incision  was  made  into  eschar  produced  by  paste,  a 
large  trocar  was  thrust  in,  and  90  ounces  of  fetid  pus  containing 
numerous  large  shreds  of  hydatid  membrane  were  drawn  off.  The 
cavity  was  washed  out  with  a  solution  of  chloride  of  zinc  (gr.  x  ad 
5j)  until  the  liquid  returned  almost  clear  ;  the  opening  was  covered 
with  lint  soaked  in  carbolic  oil,  outside  which  was  placed  a  quantity  of 
carded  oakum. 

Feb.  8. — Much  better.  Pain  much  relieved.  Temp,  normal.  Since 
Feb.  4  urine  has  again  contained  albumen  (Jjy  to  4o).  Girth  at  level 
of  opening  31  in. 

After  a  few  days  the  opening  became  choked  up,  and  the  general 
symptoms  became  worse.     The  congestion  of  the  lungs  increased  and 
there  was  great  dyspnoea.     On  Feb.  17,  60  ounces  of  pus  (not  fetid), 
with  hydatid  membranes  were  let  out  by  opening,  into  which  a  per- 
forated drainage  tube  was  fastened,  and  cavity  was  again  washed  out 
with  solution  of  chloride  cf  zinc.     Pus  without  any  fetor  was  dis- 
charged in  large  quantity  by  the  tube.     The  general  symptoms  slowly 
improved.     On    Feb.    18  albumen,  and  on  Feb.  21  bile-pigment  dis- 
appeared from  urine,  but  both  returned  on  March  2  for  a  few  days, 
during  which  the  discharge  was  occasionally  fetid   until  the  cavity 
was  again  washed  out  with  chloride  of  zinc.     The   patient,  however, 
still  suffered  much  from  cough  and  dyspnoea,  and  perspirations   at 
night,  and  from  March  8  to  15  she  had  frequent  retching.       Between 
March  14  and  17  enormous  masses  of  thick  tough  hydatid  membrane 
(parent  cyst),  came  away  while  the  cavity  was  being  washed  out,  and 
after  this  there  was  a  rapid  improvement.     On  March  24i  the  discharge 
had  almost  ceased.     On  April  1  patient  got  up.     On  May  6  tube  was 
removed,  and  on  June  6  she  left  hospital  with  Avound  almost  cicatrised. 
The  urine  was  free  from  albumen  ;  lungs  sound  ;  and  daily  gaining 
flesh  and   strength.     Lower  edge  of  liver  felt  2  in.  above  umbilicus ; 
hepatic  dulness  in  r.  m.  1.  5  in.,  and  girth  over  wound  20  in. 

In  spring  of  1875  Hannah  B.  was  free  from  all  sign  of  her  former 
disease,  but  she  had  become  enormously  fat,  and  was  a  conhrmed  spirit, 
drinker. 


i,ECT.  111.  HYDATID    TUMOUR.  99 

In  the  following  case  there  were  numerous  hydatid  cysts  in 
the  liver.  Three  of  these  were  tapped  with  success,  but 
there  was  reason  to  suspect  the  existence  of  a  larger  cyst 
deeply  seated.  It  is  to  be  regretted  that  the  patient  left  the 
hospital  before  an  attempt  was  made  to  reach  this  by  an  ex- 
ploratory puncture. 

Case  XXVI. — Multiple  Hydatid  Tumours  of  Liver — Jaundice  and 
Diarrlicea — Paracentesis  of  three  Cysts. 

Henry  A ,  aged  34,  labourer,  adm.  into  Middlesex  Hosp.  Feb. 

16,  1869.  Five  years  before  had  sustained  an  injury  of  right  side, 
from  wheel  of  a  waggon  pressing  against  it,  but  he  had  not  suffered 
much  inconvenience  from  this,  and  had  enjoyed  good  health  till  one 
day  in  Aug.  1868,  while  unloading  a  van  in  the  sun,  he  fell  and  was 
unconscious  for  three  minutes,  after  which  he  was  laid  up  for  three 
weeks  with  vomiting  and  diarrhoea  and  light  drab-coloured  motions, 
but  without  jaundice,  headache,  or  giddiness.  After  this  he  returned 
to  work,  but  suffered  from  flatulence,  pain  in  stomach  after  food,  and 
occasional  pricking  pains  in  situation  of  liver.  One  month  before  ad- 
mission he  was  again  seized  with  violent  diarrhoea,  this  time  accompa- 
nied with  jaundice,  but  without  vomiting.  About  same  time  he  first 
noticed  a  swelling  in  right  side,  and  a  feeling  of  weight,  which  was 
much  increased  whenever  he  lay  on  left  side.  The  jaundice  had  in- 
creased in  intensity  up  to  time  of  admission,  and  in  five  weeks  he  had 
lost  7  lbs.  in  weight: 

On  admission,  patient  was  fairly  nourished,  and  with  exception  of 
being  rather  deeply  jaundiced,  did  not  appear  ill.  Liver  greatly  en- 
larged, its  dnlness  in  r.  m.  1.  extending  from  ^  in.  above  nipple  to 
4  in.  below  ribs,  and  measuring  10^  in.  Corresponding  to  gall  bladder 
was  a  rounded  projection,  about  size  of  an  orange  and  distinctly  fluc- 
tuating ;  and  fluctuation  could  also  be  made  out  to  right  of  this  below 
edge  of  ribs,  the  two  fluctuating  spaces  being  separated  from  one 
another  by  a  depression  in  which  no  fluctuation  could  be  felt.  Lower 
margin  of  liver  could  be  felt  below  seat  of  fluctuation,  hard  and  sharp. 
Posteriorly  hepatic  dulness  did  not  ascend  too  high,  but  fluctuation 
was  tolerably  distinct  between  tenth  and  eleventh  ribs.  Veins  of 
abdominal  parietes  unusually  distinct,  and  splenic  dulness  increased  ; 
no  ascites  ;  diarrhoea  persisting,  five  motions  on  morning  of  admission  ; 
motions  clay-coloured  and  devoid  of  bile.  Much  flatulent  distension 
of  abdomen.  Appetite  good.  Urine  1024,  free  from  albumen,  but 
loaded  with  bile-pigment.  Pulse  40,  regular ;  heart  displaced  upwards  ; 
no  bellows-murmur.  Dyspnoea  on  exertion  and  slight  cough,  but 
physical  signs  of  lungs  normal. 

Feb.  25. — Pulse  72.     Diarrhoea  abated.     Under  ether  spray  a  fine 
trocar    was   introduced  into  anterior  fluctuating  space,  and  about  4 

H  2 


ICX)  ENLARGEMENTS    OP    THE    LIVER.  i.f.ct.  in. 

ounces  of  hydatid  fluid  drawn  off;  clear,  sp.  gr.  1011,  and  containing 
no  albumen,  but  abundance  of  chlorides.  A  wire  could  only  be 
passed  in  two  inches  through  cannula,  and  draining  away  x)f  the  liquid 
made  no  difference  in  tension  of  fluctuating  swelling  to  the  right. 

March  5. — Pulse  has  varied  from  .56  to  72,  and  temp,  has  been  nor- 
mal, but  dian-hcea  has  returned.  A  puncture  was  made  into  fluctuating 
space  to  right  of  first,  and  7  ounces  of  fluid  let  out ;  clear,  sp.  gr.  1009, 
and  containing  no  albumen,  but  much  chlorides. 

March  19. — Pulse  has  varied  from  66  to  72,  and  temp,  has  been 
normal.  Diarrhoea  and  jaundice  continue,  and  motions  contain  no  bile. 
A  rounded  elastic  tumour  about  size  of  a  turkey's  e^^  can  be  felt  in 
left  groin,  which  patient  first  observed  about  a  fortnight  ago.  Since 
March  10  there  has  been  slight  increase  of  fulness  in  situation  of  cyst 
first  tapped,  but  no  tenderness  or  fluctuation.  Urine  free  from  al- 
bumen. 

April  2. — Slight  fluctuation  without  tenderness  at  site  of  first 
puncture. 

May  7. — A  puncture  was  made  into  fluctuating  space  between  10th 
and  11th  ribs  at  back,  but  only  1^  ounce  of  clear  hydatid  fluid,  con- 
taining booklets  and  echinococci,  could  be  obtained. 

June  8. — Patient  left  hospital  of  his  own  accord,  feeling  a  good  deal 
better,  and  "with  much  less  uneasiness  in  his  side,  but  still  jaundiced, 
and  suffering  from  diarrhoea  and  flatulence. 

In  tlie  three  following  cases  there  were  numerous  cysts  in  the 
liver,  and  in  the  peritoneum.  From  tlieir  size  and  other  cha- 
racters, those  in  the  peritoneum  appeared  to  be  secondary  in 
point  of  age  to  those  in  the  liver.  In  Case  XXVII.  one  large 
cyst  in  the  liver  was  punctured  with  a  fine  trocar,  and  a  free 
opening  was  made  into  a  second  cyst  wliich  suppurated. 

Case  XXVII. — Multiple  Hydatid  Ttimours  of  Liver  and  Peritoneum — 
Paracentesis  of  one  Cyst — Suppuration  of  a  second  Cyst — Free  opening 
—Death. 

Mary  H ,  21,  adm.  into  St.  Thomas's  Hosp.  Sept.  25,  1873. 

Both  father  and  mother  had  died  of  consumption.  Four  years  ago 
noticed  a  swelling  in  right  hypochondrium,  which  has  continued  to  in- 
crease. A  year  later  observed  a  second  tumour  in  right  inguinal 
region,  and  a  third  to  right  of  umbilicus.  For  three  years  there  has 
been  swelling  of  veins  of  right  leg,  and  for  one  year  she  has  suil'ered 
from  dyspnoea  on  exertion.  Quite  recently  she  has  complained  of  sharp 
pain  in  right  hypochondrium,  and  she  has  been  losing  flesh. 

On  admission,  very  weak  ;  much  pain  in  right  side.  Abdomen 
greatly  enlarged;  girth  at  umbilicus  40  in.,  and  2  in.  above  this 
3Hi  in.  ;    from  ensiform  cartilage  to  umbilicus  8  in.,  and  from  um- 


LECT.  III.  HYDATID    TUMOUR.  10 1 

bilious  to  pubes  6^  in.  In  right  hypocliondrinm  and  epigastrium 
is  a  large  swelling,  smooth,  tense,  fluctuating,  and  not  tender. 
A  second  tumour,  about  size  of  an  orange  and  quite  movable,  can  be 
felt  in  right  inguinal  region  ;  a  third,  somewhat  smaller,  to  right  of 
umbilicus,  and  two  others  in  left  iliac  region.  All  these  tumours  are 
smooth,  rounded,  elastic,  and  distinct  from  one  another.  I^To  ascites.  Veins 
in  walls  of  abdomen  and  chest  enlarged.  In  front  of  right  chest  there  is 
dulness  on  percussion,  continuous  below  with  that  of  aforesaid  tumour, 
and  ascending  to  second  intercostal  space.  Posteriorly  lungs  resonant. 
Considerable  dyspnoea.  Apex  of  heart  beats  in  fifth  intercostal  space, 
2^  in,  outside  and  on  level  with  nipple.  Appetite  good ;  bowels 
regular. 

Oct.  20. — Three  pints  of  fluid  drawn  off"  by  aspirator  introduced  at 
most  prominent  part  of  large  swelling,  3  in.  below  ensiform  cartilage 
and  ^  in.  to  right  of  middle  line.  Fluid  clear,  alkaline  ;  sp.  gr. 
1010;  no  albumen;  much  chlorides;  no  booklets.  After  operation, 
girth  at  umbilicus  39  in.,  and  two  inches  higher  37^  in.  ;  from  ensiform 
cartilage  to  umbilicus  7  in. 

Oct.  22. — Much  less  pain,  and  breathing  easier  than  before  operation. 
Appetite  good.  Yesterday  afternoon  temperature  rose  to  100"6°  and 
to-day  it  is  101-2°. 

Nov.  13. — During  last  three  weeks  patient  has  had  much  fever, 
temperature  varying  from  99°  to  104°  ;  has  often  felt  chilly,  but  has 
had  no  rigors  or  sweating.  On  Oct.  24  vomited  once  and  had  slight 
jaundice,  which  after  a  few  days  disappeared.  On  JN^ov.  3  patient  still 
felt  better  than  before  operation  ;  girth  two  inches  above  umbilicus 
38f  inches  ;  but  after  this  pain  returned  in  large  swelling,  which  grew 
rapidly  until  to-day,  when  girth  44  in.,  some  oedema  of  legs,  but  no  albu- 
minuria. Aspirator  introduced  at  same  spot  as  before,  and  two  pints 
of  thin  opaque  yellowish  fluid  drawn  ofl".  Xo  more  could  be  obtained, 
as  cannula  became  blocked.  A  free  opening  was  now  made  into  cyst 
by  Mr.  MacCormac,  and  nine  pints  more  of  fluid  let  out,  but  cyst  was 
not  emptied.  A  large  perforated  drainage-tube  was  fixed  in  opening. 
There  was  now  clear  percussion  for  4  in.  below  right  clavicle. 

Patient  did  not  rally  ;  temp,  did  not  rise  above  100°,  but  pulse  kept 
at  140  and  was  small  and  weak,  until  death  on  Nov.  15,  48  hours  after 
operation. 

Autopsy. — Peritoneum  contained  no  fluid  and  was  nowhere  inflamed. 
Liver  much  displaced  downwards  and  to  left,  and  in  great  measure 
concealed  by  a  large  cyst,  attached  to  its  upper  surface,  which  also  en- 
croached extensively  on  thorax.  The  external  puncture  had  penetrated 
this  cyst,  the  walls  of  which  were  collapsed,  thin,  and  fibrous.  It  con- 
tained one  large  thick  gelatinous  hydatid,  but  no  secondary  cysts. 
It  showed  no  sign  of  inflammation  except  a  few  small  flakes  of  lymph 
adherent  to  its  inner  surface  (outside  hydatid).  Behind  this  cyst  was 
another,  almost  as  large,  and  with  much  thicker  walls,  which  had  also 


I02  ENLAEGEMENTS    OP    THE    LIVER.  lect.  lit. 

"been  penetrated  by  the  puncture.  This  cyst  was  also  firmly  attached  to 
liver  and  was  in  contact  with  posterior  wall  of  abdomen  ;  it  contained 
one  large  hydatid,  but  no  secondary  cysts ;  its  inner  surface  was  in- 
tensely inflamed,  partly  villous,  and  plastered  with  large  flakes  of 
yellow  lymph.  Attached  to  under  surface  of  left  lobe  of  liver  was 
a  third  cyst,  size  of  a  tennis  ball,  with  thick  walls,  and  full  of  cheesy 
matter  and  dried-up  hydatid  cysts.  No  cysts  in  interior  of  liver. 
Attached  to  peritoneum  numerous  cysts.  Just  below  liver  in  front 
of  rio'ht  kidney  were  two — one  as  large  as  a  cocoanut  and  containing 
clear  fluid  and  numerous  secondary  cysts,  and  another  somewhat 
smaller.  Six  or  seven,  of  size  of  hen's  egg  or  smaller,  were  attached 
to  great  omentum,  and  two  grew  from  fundus  of  uterus  and  broad 
ligament,  of  which  one  contained  cheesy  matter  and  shrivelled  cysts. 
Lower  part  of  both  lungs,  esj^ecially  right,  collapsed.  Other  organs 
healthy. 

In  Case  XXVI  EI.  the  history  seemed  to  leave  little  doubt 
tliat  tlie  disease  commenced  in  the  liver,  and  that  it  was  not 
until  after  many  years  that  the  peritoneum  was  secondarily  in- 
vaded. The  large  cyst  was  punctured  merely  with  the  object 
of  diminishing  the  abdominal  distension  and  affording  relief. 
But  the  cyst  was  already  before  death  much  smaller  than  it 
had  been  before  the  operation,  and  the  2>ost-mortem  exsLvamntion 
showed  that  its  size  was  mainly  kept  up  by  secondary  cysts  in 
its  interior. 

Case   XXVIII. — Multiple  Hydatid  Tumo7crs  of  Liver  and  Peritoneum — 
Ascites — Puncture  of  two  Cysts  and  Paracentesis  Abdominis. 
Charles  M ,  set.  45,  a  teacher  of  languages,  adm.  into  Middle- 
sex Hosp.  under  my  care,  March  30,  1871.     He  had  been  a  gymnast 
and  a  man  of  great  muscular  strength,  and  had  never  ailed  in  any  way 
until  1857,  when  he  noticed  one  morning  while  washing  himself  a 
tumour  over  left  lobe  of  liver.     This  tumour  was  about  size  of  half  an 
orange,  and  quite  painless ;  in  fact,  he  would  ont  have  been  aware  of 
its  presence  had  it  not  been  visible.     It  did  not  seem  to  grow,  and  in 
1859  he  first  felt  a  little  out  of  health,  complained  of  pain  under  left 
scapula,  of  occasional  dyspnoea,  and  of  a  stitch  in  region  of  tumour. 
In  1860  these  symptoms  got  better,  and  he  continued  well  until  18G3, 
when,  one  morning,  while  rubbing  his  back  with  a  towel,  he  expe- 
rienced a  dull  pain  in  epigastric  region,  which  increased  and  lasted  for 
three   weeks,  and   continued     to  recur  occasionally  for  three  years. 
During  1807  he  sufibrod  a  good  deal  of  pain  in  region  of  bladder,  with 
frequency  of  micturition,  and  urine  was  high-coloured  and  deposited  a 
reddish  sediment.     Early  in  18G0  he  had  first  noticed  a  tumour  similar" 
to  first  in  umbilical  region,  but  this  had  never  been  seat  of  any  pain. 


HYDATID    TUMOUR. 


103 


For  two  years  he  had  been  very  susceptible  of  cold,  and  in  Jan.  1870 
he  bad  suffered  from  loss  of  appetite,  cough,  and  from  a  severe  pain  in 
left  side  of  chest,  increased  on  inspiration.  For  twenty-five  years  pa- 
tient had.  lived  in  Russia  and  in  difierent  parts  of  Europe,  and  had 
eaten  food  of  countries  in  which  he  travelled. 

On  admission  into  hospital  patient  was  of  rather  spare  habit,  but 
of  unusually  good  muscular  development.  Hia  sole  complaint  was  of 
large  size  of  abdomen,  which  presented  a  distinctly  nodulated  or 
botryoidal  appearance.  In  first  place  there  was  a  large  prominence 
occupying  space  between  sternum  and  umbilicus,  but  more  to  left  than 
to  right  of  middle  line.  This  appeared  to  project  from  left  lobe  of 
liver,  and  to  be  as  large  as  a  child's  head.  It  was  fixed,  and  presented 
distinct  fluctuation,  but  no  vibration.     A  smaller  rounded  mass,  about 


Fig.  14.     The  pointed  prominence  corresponds  to  tlie  sixth  tumour.     From  a  photo- 
graph, 

size  of  a  cricket-ball,  projected  immediately  below  umbilicus  ;  this  was 
freely  movable,  and  could  be  pushed  to  right  or  to  left  of  middle  line. 
A  third,  larger  than  an  orange,  could  be  felt  projecting  from  margin  of 
right  lobe  of  liver,  and  separated  from  first  by  a  distinct  depression. 
A  fourth,  which  seemed  as  large  as  a  man's  fist,  was  in  left  iliac  region, 
but  more  deeply  seated  than  the  others.  Two  and  a  half  inches  below 
and  to  right  of  the  umbilicus,  was  a  fifth,  about  size  of  a  hen's  egg, 
freely  movable  and  not  causing  any  prominence  on  surface  of  abdomen . 
A  sixth,  movable  and  about  size  of  half  a  walnut,  appeared  to  be  in 
abdominal  parietes,  over  most  prominent  part  of  first,  immediately 
to  left  of  middle  line  (fig.  14).  Other  tumours  of  a  similar  nature 
could  be  obscurely  felt  in  diiferent  parts  of  abdomen.  All  of  tumours 
were  rounded,  soft,  and  elastic,  and  painless  even  on  free  manipulation. 
There  was  no  ascites,  and  no  jaundice.     Girth  of  abdomen  over  most 


104  ENLAEGEMENTS    OP   THE    LIVER.  lect.  hi. 

prominent  part  of  first  tumour  2  in.  below  sternum  was  36^  in., 
and  1  in.  below  umbilicus  it  was  3G  in.  Measurement  from  lower 
end  of  sternum  to  umbilicus  6^  in. ;  from  umbilicus  to  pubes  7^ 
in.  The  chief  inconvenience  which  patient  experienced  from  state 
of  his  abdomen  was  that  of  weight.  Hepatic  dulness  did  not  ascend 
too  high  into  chest,  eitlier  in  front  or  at  back.  Tongue  clean  ;  appetite 
good  ;  occasionally  slight  acidity,  but  no  other  symptoms  of  indiges- 
tion ;  bowels  regular  ;  pulse  60  ;  heart  and  lung  signs  healthy,  except 
that  breath-sounds  were  feeble  at  bases  of  lungs  ;  urine  free  from 
albumen. 

On  April  3  a  small  trocar  was  introduced  into  small  superficial 
cyst  (sixth  in  above  enumeration),  and  there  escaped  one  and  a  half 
drachm  of  clear  alkaline  fluid,  containing  abundance  of  chlorides,  but 
no  albumen.  On  microscopic  examination  there  were  no  booklets  or 
other  signs  of  echinococci.  The  puncture  was  not  followed  by  any 
pain  or  tenderness,  and  within  a  week  the  little  swelling  had  almost 
disappeared.  Patient  would  not  consent  to  any  further  interference, 
and  left  hospital  on  April  10  in  much  the  same  state  as  on  admission. 

On  March  6,  1872,  he  was  admitted  into  St.  Thomas's  Hospital 
under  my  care.  His  condition  was  now  much  worse.  His  girth  was 
40  in.  at  umbilicus,  and  40^  in.  halfvsray  between  umbilicus  and 
sternum.  This  increase  was  partly  due  to  slight  ascites,  but  mainly  to 
an  increased  size  of  tumours  ;  that  in  left  iliac  region  now  seemed  to 
be  as  large  as  a  cocoanut ;  the  distance  between  umbilicus  and  lower 
end  of  sternum  was  now  8^  in.,  and  the  hepatic  dulness  in  right 
nipple  line  now  rose  to  level  of  nipple,  and  measured  altogether  9^ 
in.  Liver  at  some  places  felt  extremely  hard,  while  at  others  it 
was  elastic  and  fluctuating.  Veins  in  abdominal  parietes  much  en- 
larged, and  considerable  oedema  of  both  legs  below  knees.  No  jaun- 
dice ;  the  abdomen  nowhere  tender ;  and  patient's  chief  complaints 
were  of  occasional  tightness  of  abdomen,  and  of  pain  in  right  shoulder. 
Pulse  84.  Urine  contained  a  small  quantity  of  bile-pigment,  but  no 
albumen. 

Abdomen  continued  to  increase  in  size,  so  that  on  March  27  it 
measured  43  inches  at  umbilicus,  and  breathing  was  beginning  to  be 
embarrassed.  A  puncture  was  made  on  this  day  with  a  fine  trocar 
into  large  cyst  between  umbilicus  and  sternum,  and  28  fluid  ounces  of 
hydatid  liquid  were  drawn  off",  having  an  alkaline  reaction  and  a  spe- 
cific gravity  of  1009,  and  containing  much  chlorides,  but  no  albumen  ; 
no  traces  of  echinococci  on  microscopic  examination ;  but  it  was 
noted  that  there  were  constant  interruptions  to  escape  of  the  fluid  by 
cannula.  Girth  at  umbilicus  immediately  after  tapping  was  reduced 
to  40^  in. 

On  March  29  temperature  rose  to  1034°,  and  for  a  week  it  ranged 
between  101°  and  102°,  but  no  retching  nor  abdominal  tenderness. 
The  ascites,  however,  and  enlargement  of  abdominal  veins  rapidly 


tECT.  III.  HYDATID    TUMOUR.  IO5 

increased,  and  there  was  also  a  considerable  increase  of  oedema  of 
legs. 

On  April  1  girtli  at  umbilicus  44  in.,  and  on  the  10th,  46 
in.  Orthopncea  set  in ;  patient  was  obliged  to  sleep  sitting  up  in 
a  chair ;  and  he  occasionally  suffered  from  severe  attacks  of  suffoca- 
tive dyspnoea.  Under  these  circumstances  paracentesis  abdominis  was 
resorted  to,  and  140  fluid  ounces  of  serum  were  drawn  off  from  perito- 
neum ;  alkaline,  specific  gravity  1016,  and  loaded  with  albumen.  The 
operation  gave  great  relief,  and,  what  was  remarkable,  fluid  did  not 
reaccumulate  in  peritoneum.  On  morning  after  paracentesis  girth  at 
umbilicus  was  41  inches,  and  on  April  29  it  was  only  37i  inches. 
On  latter  date,  also,  girth  round  most  prominent  part  of  tumour  in 
epigastrium  was  only  38  in.,  being  2^  in.  less  than  at  time  he 
was  admitted  into  hospital.  The  distance  also  from  umbilicus  to 
sternum  measured  only  7^  in.,  being  1  in.  less  than  on  admis- 
sion. (Edema  almost  disappeared  from  legs,  and  patient  was  able  to 
get  up  and  walk  about  a  little.  Both  before  and  after  paracentesis 
patient  took  diuretics,  including  blue  pill,  squill,  and  digitalis. 

On  May  1  he  seemed  to  be  as  well  as  usual,  and  got  up  for  a  short 
time  in  evening,  but  after  getting  into  bed,  his  breathing  became  sud- 
denly embarrassed,  and  in  twenty  minutes  he  was  dead.  His  con- 
sciousness continued  to  the  last,  and  he  complained  of  no  acute  pain. 

Autopsy. — Peritoneum  contained  less  than  a  pint  of  clear  straw- 
coloured  serum,  Nowhere  any  traces  of  recent  peritonitis.  Two 
enormous  cysts  in  liver,  one  in  front  growing  down  from  under  surface 
of  left  lobe,  and  containing  an  enormous  number  of  hydatid  cysts,  with 
a  small  quantity  of  thin  pus,  the  entire  contents  measuring  six  pints. 
This  was  the  cyst  which  had  been  tapped.  The  other  cyst  was  in  back 
part  of  right  lobe,  and  contained  between  four  and  five  pints  of  thin 
opaque  fluid,  in  which  there  was  bile-pigment,  with  a  few  hydatid 
cysts.  Numerous  smaller  cysts  were  found  in  liver,  and  growing  from 
omentum  and  other  parts  of  peritoneum.  Altogether  there  must  have 
been  many  hundreds  of  them.  There  was  one  as  large  as  a  man's  fist 
in  spleen,  and  another  still  larger  in  left  iliac  region ;  another  of  size 
of  a  large  orange,  and  quite  globular,  was  attached  by  a  narrow  pedicle 
just  below  umbilicus ;  and  two,  as  large  as  oranges,  and  with  thick 
opaque  white  coats,  lay  quite  loose  in  peritoneal  cavity  in  right  flank. ^ 

Heart  small  and  flabby  ;  it  contained  no  hydatids,  and  there  was 
no  thrombosis  of  the  pulmonary  artery.  Lower  part  of  both  lungs 
condensed,  apparently  from  pressure  ;  and  left  lung  everywhere  firmly 
adherent  to  wall  of  chest. 

Nothing  was  found  to  account  for  patient's  sudden  death. 

Case  XXIX.  is  remarkable  for  the  successful  excision  by  Mr. 
Spencer  Wells  of  an  immense  number  of  hydatid  cysts  from  the 
peritoneum. 

'  See  also  Case  XLIV. 


io6 


EISTLARGEMENTS    OP    THE    LIVER. 


Case  XXIX. — Multiple  Hydatid  Tumours  of  the  Liver  (?)  a7td  Peri- 
toneum, in  part  successfally  removed  by  operation. 

Elizabeth  C ,  agt.  29,  adm.  into  Middlesex  Hosp.  under  my  care 

on  December  12,  1870.  She  had  previonsly  been  in  Samaritan  Hos- 
pital, under  care  of  Mr.  Spencer  Wells,  who  was  good  enough  to 
transfer  her  to  me. 

On  admission  patient  was  pale,  weak,  and  thin,  but  her  countenance 
was  not  expressive  of  pain  or  cachexia.  Her  sole  complaint  was  of 
swelling  of  abdomen,  which  measured  33^  inches  at  umbilicus.  Ab- 
domen generally  was  soft  and  elastic,  and  nothing  like  a  solid  tumour 
could  be  felt ;  neither  was  swelling  due  to  an  accumulation  of  gas  in 
bowel,  for  greater  part  of  it  was  dull  on  percussion  ;  nor  was  it  due  to 
ascites,  for  as  patient  lay  on  her  back  there  was  tympanitic  percussion 
in  left  flank.  On  careful  inspection  of  abdomen  swelling  was  seen  not 
to  be  uniform,  but  was  marked  by  a  number  of  small  rounded  pro- 
minences, corresponding  to  rounded  movable  tumours,  from  size  of  a 
cheny  to  that  of  an  orange,  which  could  be  felt  in  large  numbers,  and 
some  of  which  were  even  visible  tbrovigh  abdominal  parietes  (fig.  15.) 


Fig.  15.     From  a  photograph. 

Several  of  these  could  be  felt  projecting  from  below  right  ribs,  but 
whether  they  were  attached  to  liver  or  not  could  not  be  determined. 
All  of  them  were  rounded  and  very  elastic,  and  in  one  of  largest, 
situated  to  right  of  umbilicus,  distinct  vibration  could  be  made  out  on 
percussion.  Hepatic  dulness  reached  to  upper  border  of  fourth  rib, 
but  lower  margin  of  liver  could  not  be  defined  from  dulness  duo  to  the 
nodular  mass  filling  abdomen.  Abdomen  was  nowhere  tender  on 
pressure,  and  only  pain  patient  complained  of  was  that  of  abdominal 
distension,  increased  after  a  full  meal.  Appetite  fair;  no  evidence  of 
disease  of  kidneys,  or  of  thoracic  organs  ;  but  patient  suffered  a  good 


LECT.  Til.  HYDATID    TUMOUE.  lO/ 

deal  from  dyspnoea,  owing  to  pressure  upwards  against  diapliragm,  and 
apex  of  heart  could  be  felt  beating  as  high  as  third  intercostal  space. 

The  history  which  the  patient  gave  was  this  : — Her  father,  mother, 
and  three  sisters  were  alive  and  in  good  health,  and  there  was  no 
history  of  phthisis  or  of  cancer  in  family.  Excepting  diseases  of  child- 
hood, patient  herself  had  enjoyed  good  health  until  age  of  nineteen. 
She  was  married  at  eighteen  ;  twelve  months  afterwards  she  gave  birth 
to  a  child,  and  three  months  after  this  she  awoke  one  night  with  severe 
pain  below  right  ribs,  vomiting,  and  faintness,  and  she  discovered  for 
first  time  a  swelling  of  size  of  a  hen's  egg  in  situation  of  pain.  After 
several  days  pain  and  vomiting  subsided,  but  from  that  time  patient 
had  never  been  so  well  as  she  had  been  before  ;  she  had  no  definite 
illness,  but  felt  weak  and  languid.  The  swelling  below  right  ribs  con- 
tinued, without  increasing  notably  in  size,  and  three  or  four  years  after- 
wards she  noticed  a  similar  swelling  in  left  iliac  region,  painless  from 
the  first,  but  which  gradually  increased  in  size.  After  this  she  had  at 
varying  intervals  paroxysms  of  abdominal  pain,  not  limited  to  situation 
of  the  appreciable  swellings,  but  general.  The  pain  would  last  for  several 
days,  and  while  it  lasted  she  would  scream  out  and  retch  very  much . 
Nine  months  before  admission  she  first  noticed  the  numerous  lumps 
scattered  over  abdomen,  and  about  same  time  she  began  to  lose  flesh. 
After  commencement  of  her  disease  patient  became  four  times  pregnant, 
and  of  her  five  children  four  were  alive  and  in  good  heali-h,  the  fifth 
having  died  of  convulsions  at  age  of  a  month.  In  intervals  of  her 
pregnancies  catamenia  had  been  regular,  but  for  two  years  before  ad- 
mission, uterus  had  prolapsed  when  she  walked  about. 

The  diagnosis  arrived  at  was  that  abdominal  swelling  was  due  to 
multiple  hydatid  tumours  of  liver  and  peritoneum,  and  that  liver  had 
in  all  probability  been  primarily  affected.  It  was  pi-oposed  to  test  this 
diagnosis  by  tapping  one  of  largest  tumours  with  a  fine  trocar,  but 
the  patient  would  not  consent  to  this,  and  left  hospital  on  Dec.  19. 

On  Dec.  31  she  was  re-admitted  into  Samaritan  Hospital  under 
care  of  Mr.  Spencer  Wells,  who,  on  Jan.  12,  1871,  tapped  large  cyst 
to  right  of  umbilicus,  and  obtained  one  fluid  ounce  of  clear  hydatid 
fluid  containing  much  chlorides,  but  no  albumen.  Finding  no  cyst 
large  enough  to  make  any  difierence  in  size  of  abdomen  by  tapping, 
Mr.  Wells  proceeded  to  make  a  small  incision  through  abdominal 
parietes,  and  through  this  he  removed  three  or  four  pounds  of  hydatid 
cysts  ^  from  omentum  and  mesentery,  leaving  at  least  as  many  more 
scattered  all  over  abdominal  wall,  omentum,  mesentery,  and  coats  of 
intestines.  The  condition  of  liver  and  spleen  was  not  observed  during 
operation.  Patient  had  no  bad  symptom ;  within  ten  days  wound 
healed,  and  in  less  than  a  month  she  left  hospital  considerably  relieved 
of  the  uncomfortable  feeling  of  abdominal  distension. 

For  nine  months  patient  continued  much  relieved,  but   gradually 
'  Now  in  museum  of  St.  Thomas's  Hospital. 


I08  ENLARGEMENTS    OF    THE    LIVER.  i.ect.  hi. 

abdomen  again  became  enlarged,  and  about  middle  of  October  Mr. 
Wade,  of  Greenwich,  who  was  called  to  see  her,  found  her  very  prostrate, 
with  great  enlargement  of  abdomen,  which  had  a  distinctly  nodulated 
appearance.  After  this  she  had  persistent  vomiting  and  purging,  and 
she  died  at  last  by  astbenia.     There  was  no  post-mortem  examination, 

111  Case  XXX.  a  hydatid  of  the  liver  was  evacuated  by  a  large 
and  permanent  opening.  The  patient  ultimately  recovered,  but 
from  the  history  it  seemed  clear  that  subsequently  to  the  ope- 
ration a  cyst  in  the  liver  discharged  itself  through  the  right 
lung.  It  is  impossible  to  say  whether  this  was  the  cyst  which 
had  been  punctured.  The  fact  that  bile  was  expectorated,  and 
that  none  was  ever  observed  in  the  discharge  from  the  external 
opening,  suggests  that  it  was  not. 

Case  XXX. — Hydatid  Tumour  of  Liver — Evacuation  hy  a  large  opening 
— Subsequent  htirstivg  of  Hydatid  through  diaphragm  into  Lung. 

Elizabeth  R ,  39,  lady's-maid,  adm.  into  St.  Thomas's  Hosp. 

July  25,  1874.  Father  died  at  71,  and  mother  at  75.  Two  sistei-s  and 
one  brother  died  of  consumption  ;  two  brothers  and  one  sister  alive 
and  well.  Although  not  very  strong,  patient  had  never  been  ill  from 
childhood  till  two  months  ago,  when  she  began  to  feel  a  sharp  pain  and 
a  sensation  of  dragging  down  from  shoulders  in  epigastrium  and  right 
hypochondrium,  accompanied  by  occasional  vomiting,  and  after  a  few 
days  by  slight  jaundice.  The  jaundice  and  sickness  soon  subsided,  but 
the  pain  persisted.  A  few  days  after  commencement  of  pain,  she  first 
noticed  a  swelling  below  right  ribs — considerable  at  first,  but  which 
gradually  increased  up  to  admission. 

On  admission,  still  complains  of  pain  as  described  above.  Pro- 
jecting downwards  from  right  lobe  of  liver  is  a  tumour,  about  size  of 
a  cocoanut,  globular,  smooth,  very  elastic,  and  not  tender.  No  jaun- 
dice or  ascites.     Pulse  108.     Temp.  100-4°. 

During  August  and  September  I  was  absent  from  hospital,  and 
but  few  notes  of  patient's  case  were  recorded.  On  Aug.  15  tumour 
was  noted  as  tender ;  and  on  Aug.  24,  patient  having  again  become 
slightly  jaundiced,  tumour  was  punctured,  first  with  a  small  and  then 
with  a  large  trocar,  and  the  contents  evacuated.  These  consisted  of 
a  clear  fiuid  with  a  number  of  hydatid  cysts  and  echinococci.  A 
cannula  was  tied  in,  the  cavity  was  washed  out  from  time  to  time,  and 
an  ice-bag  applied  over  part. 

On  Sept.  5  it  was  noted  that  patient  was  very  weak  and  anoemic, 
and  pulse  feeble.  Since  Aug.  28  there  had  been  no  jaundice.  On 
^ept.  14  she  again  complained  of  great  pain  in  right  side,  with  fever 
(temp.  101").  She  had  also  frequent  cough  and  expectorated  mucus 
of  a  briglit  yellow  colour  from  admixture  of  bile.  Over  lower  half  of 
right  lung  at  back  there  was  dulness  on  percussion  with  feeble  breath- 


LECT.  III.  HYDATID    TUMOUE.  IO9 

ing,  diminished  vocal  fremitus,  and  distant  crepitation.  Anteriorly 
also  there  was  dulness  as  high  as  nipple.  The  pain  and  fever  subsided 
after  about  a  week,  but  on  Oct.  6  she  was  still  expectorating  bile,  and 
the  dulness  and  other  signs  remained  at  base  of  right  lung.  The  ex- 
ternal opening  was  now  closed,  and  at  no  time  had  there  been  any  dis- 
charge of  bile  by  it.  ISTo  hydatid  membrane  or  signs  of  echinococci 
had  been  found  in  sputum,  but  it  contained  bile  up  to  Oct.  12.  Pa- 
tient continued  for  a  long  time  very  weak,  and  was  not  able  to  leave 
her  bed  until  Nov.  21,  by  which  time  base  of  right  lung  had  become 
clear.  On  Dec.  18  the  catamenia  returned  after  an  absence  of  six 
months,  and  by  the  end  of  the  month  she  was  able  to  leave  the  hospital. 

In  tlie  four  following  cases  a  hydatid  of  the  liver  opened  into 
the  bile-duct,  which  became  obstructed  by  hydatid  vesicles,  so 
that  jaundice  resulted.  In  Case  XXXI.  the  liver  contained 
three  cysts,  two  of  which  communicated  with  one  another,  and 
had  suppurated  before  the  patient  came  under  observation. 
Paracentesis  was  resorted  to  solely  as  a  palliative.  The  case 
was  also  interesting  from  the  circumstance  that  the  patient's 
brother  had  also  a  hydatid  of  the  liver. 

Case  XXXI. — 8v.ppurating  Hydatid  Tumours  of  Liver,  one  opening  into 
Lung  and  another  into  Bile-duct — Jaundice — Temporary  relief  from 
Paracentesis. 

Charles  W ,  aged  24,  adm.  into  Middlesex  Hosp.  May  19,  1869. 

Had  enjoyed  good  health  until  12  months  before,  when,  after  getting 
wet  in  a  thunderstorm,  he  was  laid  up  for  two  months  with  inflamma- 
tion in  chest,  on  recovering  from  which  he  suffered  for  a  week  from 
headache  and  vomiting,  and  ever  since  he  had  complained  of  general 
debility  and  lassitude.  Eight  months  before  admission  he  began  to 
complain  of  vomiting  in  morning,  and  drowsiness  and  tightness  at 
epigastrium  after  meals,  but  notwithstanding  persistence  of  these  sym- 
ptoms he  continued  at  work  until  three  weeks  before  coming  to  hospital, 
when  symptoms  became  worse,  he  lost  flesh  and  suffered  from  great 
itchiness  of  skin,  and  first  became  aware  of  a  swelling  in  right  hypo- 
chondrium,  which  had  continued  to  enlarge  up  to  admission.  Ten 
days  before  admission,  jaundice  appeared,  and  his  motions  became 
slate-coloured. 

On  admission,  patient  was  deeply  jaundiced,  prostrated,  thin,  and 
with  anxious  pinched  features.  Liver  appeared  enormously  enlaro-ed, 
so  as  to  cause  a  visible  bulging  of  upper  part  of  abdomen.  Following 
measurements  were  taken  in  recumbent  posture.  Girth  at  umbilicus 
36  in. ;  half-way  between  umbilicus  and  sternum,  38;|  in. ;  at  lower 
end  of  sternum,  37^  in.  ;  from  lower  end  of  sternum  to  umbilicus,  7^  in. ; 
from  umbilicus  to  pubes,  6  in.     Hepatic  dulness  in  r.  m.  1.  commenced 


no  ENLARGEMENTS    OF    THE    LIVER.  lect.  m. 

an  inch  above  nipple  and  extended  to  half  an  inch  below  umbilicns, 
measurino"  12 j  in.  Lower  margin  of  liver  rounded  ;  surface  smooth 
and  painless,  and  to  right  of  middle  line  distinctly  fluctuating  and 
yieldintr  '  hydatid  vibration.'  Projecting  from  lower  margin  of  left 
lobe  Avas  a  circumscribed  fluctuating  bulging  about  size  of  an  orange, 
apparently  distinct  from  cyst  in  right  lobe.  Also,  behind  large  cyst  on 
right  side  could  be  felt  another  rounded  projection  from  liver,  without 
any  distinct  fluctuation.  Peritoneal  hepatic  dulness  ascended  as  high 
as  5th  dorsal  spine.  Subcutaneous  veins  in  right  axillary  and  lumbar  re- 
gions enlarged,  and  evidence  of  slight  ascites.  Tongue  clean  ;  appe- 
tite fair,  but  afraid  to  eat  much  on  account  of  painful  feeling  and  dis- 
tension ;  3  or  4  loose  motions  daily,  devoid  of  bile.  Urine  loaded  with 
bile-pigment,  but  free  from  albumen.  Pulse  80  ;  heart  elevated,  its 
apex  beating  between  3rd  and  4th  ribs.  Considerable  dyspnoea,  and 
slight  crepitation  at  base  of  right  lung. 

May  "7. — Diarrhoea  has  persisted,  but  dyspnoea  and  feeling  of  abdo- 
minal tightness  have  increased.  An  exploratory  puncture  was  made 
to-day  into  cyst  in  right  lobe  of  liver.  Seven  ounces  of  fluid  were 
drawn  off,  viscid,  yellowish,  and  containing  pus-corpuscles,  shreds  of 
hydatid  membrane,  booklets,  and  rhomboidal  blood  crystals. 

May  29. — Pulse  84  ;  temp.  98'2°.  To-day  a  tine  trocar  was  passed 
into  cyst  in  left  lobe.  Only  a  few  drops  of  bright  yellow  matter  of 
the  consistence  of  clotted  cream  could  be  squeezed  out ;  this  con- 
tained oil-globules,  nuclei,  and  abundance  of  booklets,  and  minute  red 
rhombic  crystals. 

June  3. — Cyst  in  right  lobe  was  again  opened  with  a  large  ti'ocar 
under  ether  spray.  Eighty  ounces  of  yellow  pus  were  let  out,  con- 
taining numerous  collapsed  hydatids  and  fragments  of  cysts  ;  last  few 
ounces  were  deeply  tinged  with  blood.  In  consequence  of  haemorrhage 
cannula  was  withdrawn  and  wound  closed  with  collodion,  although 
cavity  did  not  appear  nearly  emptied. 

June  8. — Pulse  96 ;  temp.  98'2°.  Great  relief  followed  last  opera- 
tion, but,  cyst  apparently  filling  again,  it  was  determined  fco  make  a 
free  opening  into  it.  On  again  introducing  large  cannula,  much  blood, 
partly  clotted,  escaped  with  hydatid  membranes,  and  after  4  ounces 
had  been  drawn  ofi"  opening  was  again  closed. 

June  18. — Patient  left  hospital  at  his  own  request.  Still  deeply 
jaundiced  and  suffering  from  diarrhoea.  Temperature  since  last  opera- 
tion has  never  exceeded  normal  standard.  Girth  over  most  prominent 
part  of  tumour,  38  in. 

June  28. — After  discharge,  tumour  continued  to  enlarge,  and  to-day 
patient's  wife  came  to  say  that  he  had  been  suddenly  seized  with  most 
profuse  diarrhcea  and  had  ])asscd  '  pieces  of  skin  '  and  '  bits  of  jolly  '  in 
motions,  while  at  same  time  swelling  in  side  had  become  suddenly  less. 
Juli/  3. — Much  thinner  and  weaker,  and  has  no  appetite  and  much 
thirst,  but  jaundice  almost  gone.     Girth  over  most  promineut  part  of 


lECT.  ni.  •  HYDATID    TUMOUR.  I  I  I 

tumour  now  only  34^  inches.  Right  lobe  of  liver  comparatively  flat, 
so  that  cyst  in  left  lobe  appears  much  more  prominent.  Diarrhoea  con- 
tinues, but  less  profuse.  The  same  evening  patient  became  suddenly 
collapsed,  and  died  on  evening  of  July  4. 

Autopsy. — Girth  of  abdomen  over  most  prominent  part  of  tumour, 
33f  in.  Abdominal  parietes  and  transverse  colon  firmly  adherent 
to  right  lobe  of  liver,  and  also  some  recent  lymph  over  rest  of 
liver  and  adjacent  bowels.  Peritoneum  contained  a  pint  of  fluid. 
Mucous  membrane  of  adherent  colon  intact.  Duodenum  contained  bile 
aud  several  small  hydatid  cysts,  and  dark  green  bile  could  be  squeezed 
into  it  through  dilated  orifice  of  bile-duct.  Common  bile-duct  greatly 
dilated,  so  that  a  JSTo.  8  bougie  could  be  passed  with  ease  through 
duodenal  opening  into  large  cyst  in  right  lobe.  This  cyst  was  as  large 
as  a  child's  head  and  contained  much  reddish-brown  pus,  with  nu- 
merous hydatid  cysts  up  to  size  of  a  small  orange,  some  collapsed,  but 
others  full  and  plump.  The  parent  cyst  was  collapsed  and  ruptured, 
having  sepai-ated  from  wall  of  cavity,  which  was  lined  with  flocculent 
lymph.  This  large  cavity  communicated  with  another  almost  as  large, 
also  in  right  lobe  of  liver,  but  higher  up,  by  a  well-defined  circular 
opening  just  large  enough  to  admit  tip  of  finger.  This  cyst  had  simi- 
lar contents  to  first,  and  was  firmly  adherent  to  diaphragm,  which  in 
its  turn  adhered  firmly  to  base  of  right  lung.  The  diaphragm  was  at 
this  part  perforated,  and  in  the  opposed  part  of  lung  was  a  cavity,  the 
size  of  an  apricot,  with  ragged  walls  of  pulmonary  tissue  and  traversed 
by  bands  of  disintegrating  lung.  There  was  no  fluid  or  hydatids  in 
right  pleura.  These  two  cysts  occupied  greater  part  of  right  lobe  of 
liver.  Left  lobe  of  liver  was  also  much  enlarged,  and  projecting  from 
its  anterior  margin  was  a  third  cyst,  larger  than  a  man's  fist,  with 
thick  walls  infiltrated  with  calcareous  matter,  and  its  interior  full  of 
a  bright  yellow  pulp  containing  innumerable  booklets  of  echinococci 
and  blood-crystals.     Other  organs  healthy. 

In  June  1870,  Thomas  W.,  aged  27,  brother  of  above  patient,  con- 
sulted me  on  account  of  an  elastic  fluctuating  tumour  in  epigastrium, 
the  size  of  a  cocoanut,  and  causing  a  bulging  of  costal  cavities  on  both 
sides.  He  had  first  noticed  it  four  months  before.  It  was  unattended 
by  pain  or  constitutional  symptoms.  He  had  lived  for  a  short  time 
with  his  brother  2^  years  before,  but  never  before  then  during  14  years. 
He  would  not  consent  to  any  operation. 

In  the  following  case,  whicli  you  must  all  have  watched 
with  much  interest,  we  were  enabled  to  diagnose  during  the 
patient's  life  that  a  communication  had  been  established  be- 
tween the  tumour  and  the  common  bile-duct.  The  fact  that 
the  tumour  had  undergone  suppuration  and  that  the  contents 
were  fetid  contra-indicated  the  ordinary  operation,  and  com- 
pelled us  to  substitute  a  large  permanent  opening. 


112  ENLAEGEMENTS    OF    THE    LIVER.  LECT.  in. 

Casr  XXXII. — Hijclatid  Tumour  of  Liver,  opening  into  the  common 
Bile-duct. — Jaundice  and  Suppuration  of  Cyst — Puncture  u-ith  a  large 
Trocar,  and  permanent  Opening — Pneumonia — Death. 

On  February  4,  1868,  I   was  requested  by  Dr.  Ayling,  of  Great 

Portland  Street,  to  see  Mrs.  C ,  aged  30,  who  was  suffering  from 

jaundice  and  enlargement  of  liver.  Her  mother  stated,  that  ever  since 
she  had  been  fourteen  there  had  been  a  fulness  in  epigastrium  and  left 
hypochondrium,  but  that,  with  exception  of  occasional  pain  after  food 
and  other  svmptoras  of  indigestion,  she  had  enjoyed  good  health  until 
present  illness.  She  had  been  married  for  eleven  years,  and  during 
that  period  catamenia  bad  been  regular,  and  she  had  had  no  children 
or  miscarriages.  Eighteen  days  before  I  saw  her,  she  had  been  sud- 
denly seized  with  severe  pain  in  back  and  upper  part  of  abdomen,  which 
almost  bent  her  double.  This  was  relieved  by  warm  poultices  &c., 
but  was  soon  followed  by  pyrexia,  and  four  days  later  by  jaundice, 
which  soon  became  intense,  with  dark  porter-coloured  urine,  and  a  com- 
plete absence  of  bile  from  motions.  The  fever  continued  ;  the  swelling 
in  epigastrium  and  left  hypochondrium  was  observed  to  increase,  and 
patient  was  so  prostrate  that  some  days  before  I  saw  her  she  was 
thought  to  be  sinking  ;  but  she  had  no  vomiting,  rigors,  or  night- 
sweats. 

I  found  patient  much  emaciated,  and  with  deep  jaundice  of  con- 
junctivae and  whole  surface  of  body.  There  was  a  distinct  tumour  in 
epigastrium,  extending  apparently  into  both  hypochondria.  It  pro- 
jected forwards  fully  1^  in.  beyond  natural  level,  and  pushed  forward 
lower  end  of  sternum,  and  lower  ribs  on  both  sides,  but  particularly  on 
left.  When  patient  lay  on  her  back,  lower  margin  of  tumour  was 
1  in.  above  umbilicus.  Tumour  was  evidently  connected  with  liver, 
dulness  of  which  in  mesial  line  was  9  in.,  in  right  mammary  line  5 
in.  and  in  left  6  in.  Posteriorly  and  laterally  hepatic  dulness  did 
not  rise  higher  than  natural  on  right  side,  but  on  left  posteriorly, 
it  was  fully  2  inches  higher  than  on  right,  and  the  dulness  in  left 
axillary  line  was  9  in.  The  tumour,  where  it  presented  itself  at 
epigastrium,  was  rounded,  smooth,  and  slightly  tender.  Distinct  fluc- 
tuation could  be  felt  in  it,  and  a  thrill,  as  from  fluid,  could  be  made 
out  in  epigastrium  when  percussion  was  made  over  the  dull  part  at 
back  of  left  side  of  chest.  Tongue  very  red  and  clean,  with  enlarged 
papilln^  at  tip  ;  centre  smooth  and  deeply  fissured.  Motions  clay- 
coloured,  without  a  trace  of  bile-pigment.  Pulse  108.  Apex  of  heart 
elevated  by  tumour  to  between  fourth  and  fifth  ribs.  Respirations  28, 
and  slightly  embarrassed,  but  pulmonary  signs  normal.  Temperature 
100-6°.  LFrine  1027,  containing  both  bile-pigment  and  bile-acids 
(Harley's  test),  but  no  albumen. 

The  fact  that  tumour  contained  fluid,  and  had  probably  existed  for 
years  without  giving  rise  to  symptoms,  indicated  hydatid;  the  acute 


HYDATID    TtMOUR. 


113 


pain,  followed  by  janndice,  with  disappearance  of  bile  from  stools,  made 
it  probable  that  this  hydatid  had  communicated  with  and  obstructed 
the  main  bile-duct ;  while  the  enlargement  of  tumour,  with  fever  and 
great  prostration,  was  accounted  for  by  inflammation  of  tumour  con- 
sequent on  entrance  of  bile.     This  was  the  diagnosis. 

On  following  day  patient  was  admitted,  under  my  care,  into 
Middlesex  Hospital,  and  as  her  condition  became  daily  more  critical  it 
was  determined  to  have  recourse  to  puncture  of  the  tumour,  as  holding 
out  the  only  chance  of  safety.  Accordingly,  on  Feb.  7,  a  fine  trocar 
was  introduced  by  Hulke  in  left  side  of  epigastrium,  and  about  six 
ounces  of  fluid  drawn  off".  This  was  deeply  tinged  with  bile  and  very 
fetid,  and  contained  numerous  pus-corpuscles  and  scales  of  cholesterin 
but  no  booklets  or  echinococci.  On  ascertaining  nature  of  fluid  small 
cannula  was  withdrawn,  and  a  full-sized  trocar  substituted.  Several 
hydatid  vesicles  escaped  through  the  larger  tube,  but  only  about  eight 
ounces  more  of  fluid,  although  a  probe  could  be  passed  in  6  or  8  in. 
It  appeared,  therefore,  that  contents  of  cyst  consisted  mainly  of  hydatid 
vesicles.  A  solution  of  carbolic  acid  (2  per  cent.)  was  injected  into 
cavity,  and  a  large  tube  was  tied  into  wound. 

During  the  ten  days  that  followed  operation,  several  pints  of  the 
carbolic  acid  solution  were  injected  three  times  a  day  through  an  elastic 
catheter  passed  into  cavity,  and  on  each  occasion  large  numbers  of 
hydatid  vesicles  (with  booklets  and  echinococci  in  some)  came  away 
with  a  fetid,  purulent  fluid,  containing  a  large  quantity  of  green  bile. 
While  this  was  going  on,  abdomen  returned  to  almost  its  normal  dimen- 
sions, and  the  jaundice  in  a  great  measure  disappeared  from  integu- 
ments and  urine,  but  motions  remained  as  light  as  before. 

Patient  had  repeated  doses  of  morphia  after  operation,  and  for  four 
days  pulse  was  about  108,  temperature  was  normal,  and  no  very  bad 
symptom,  except  development  on  tongue  and  inside  of  mouth  of 
numerous  aphthous  ulcers  on  a  raised  base,  which  caused  excruciating 
pain  whenever  she  took  food  or  drinks  ;  but  both  pain  and  ulcers 
almost  disappeared  after  repeatedly  washing  out  mouth  with  Condy's 
'  ozonised  water.'  During  night  of  Feb.  11,  patient  suS"ered  from  re- 
peated rigors,  and  after  this  pulse  rose  to  140,  respirations  became 
quick,  and  tongue  dry  ;  occasional  vomiting,  and  prostration  rapidly  in- 
creased.    On  morning  of  18th  delirium  set  io,  and  at  6  p.m.  she  died. 

On  opening  abdomen,  peritoneum  contained  no  fluid,  and  there  was 
no  sign  of  recent  peritonitis,  but  there  were  firm  adhesions  between 
tumour  and  diaphragm  and  abdominal  parietes  in  front.  Left  lobe  of 
liver  had  disappeared,  and  its  place  was  occupied  by  an  enormous  hy- 
datid cyst.  This  cyst  contained  about  two  pints  of  very  fetid  thick 
green  fluid,  with  large  fragments  of  parent  hydatid  cyst  lying  loose  in 
cavity.  It  opened  externally  through  wound  in  abdominal  wall,  while 
internally  it  communicated  with  common  bile-duct  by  an  opening  large 
enough  to  admit  a  full-sized  catheter.     On  slitting  open  duodenum 

I 


I  14  ENLARGEMENTS    OF   THE    LIVER.  MiCT.  in. 

orifice  of  duct  was  found  sufficiently  dilated  to  admit  a  goose-qnill,  but 
obstructed  by  a  large  hydatid  cyst,  partially  protruded  into  duodenum.' 
Between  this  and  the  opening  into  cyst,  duct  was  distended  with  hydatid 
vesicles.  Bile-ducts  throughout  liver  greatly  dilated,  and  liver  itself  very 
fattv  and  intensely  jaundiced,  with  a  tight-lace  prolongation  down- 
wards of  right  lobe.  No  trace  of  bile-pigment  in  intestinal  contents. 
Spleen  adherent  to  tumour,  but  otherwise  normal ;  kidneys  healthy. 
Recent  pneumonia,  at  some  places  passing  into  condition  of  grey 
hepatisation,  of  back  of  lower  lobe  of  both  lungs  and  of  upper  lobe  of 
right. 

The  following  case  was  in  some  respects  very  similar  to  the 
last.  The  attack  of  diarrhoea  was  probably  due  to  the  partial 
discharge  of  the  contents  of  the  cyst  through  the  bile-duct  into 
the  bowel. 

Case   XXXIII. — Hydatid  T^imo^ir   of  Liver    opening  into  Bile-dud — 
Jaundice  frovi  obstruction  of  duct  hy  Hydatid  Membrane — Pycemia. 

Jane  R.,  33,  charwoman,  admitted  into  St.  Thomas's  Hosp.  Nov. 
13,  1874.  Nothing  of  importance  in  family  history.  Married  and  had 
five  children,  of  whom  three  are  alive  and  well.  Had  '  typhoid  fever  ' 
two  years  ago,  but  on  whole  had  good  health  till  eight  months  ago,  when 
she  began  to  complain  of  an  occasional  gnawing  pain  in  right  hypochon- 
drium,  which  after  three  months  spread  up  to  the  shoulders.  These  pains 
did  not  prevent  her  going  about  following  her  work,  but  she  was  usually 
ailing  and  she  lost  flesh.  A  month  before  admission  the  pain  became 
much  increased,  and  after  a  fortnight  she  was  suddenly  seized  with 
very  acute  shooting  pain  in  right  hypochondrium  attended  by  rigors  and 
vomiting,  and  followed  after  two  days  by  jaundice,  urine  like  porter, 
and  white  stools.  She  had  kept  her  bed  from  commencement  of  this 
acute  attack  until  admission.  Six  weeks  before  admission,  she  first 
noticed  a  tumour  in  right  lumbar  region,  which  was  then  comparatively 
small,  and  appeared  to  be  movable.  This  rapidly  increased  in  size, 
especially  during  last  three  weeks. 

State  on  Admission. — Very  prostrate  and  emaciated,  but  did  not 
complain  of  much  pain.  Decided  jaundice  of  skin  and  conjunctivae. 
No  dropsy.  Tongue  clean,  but  dry  down  centre;  sordes  on  lips ;  no 
appetite  ;  bowels  confined  ;  an  enema  brought  away  some  white  fnccal 
matter.  Hepatic  dulness  much  increased,  commencing  |  inch  below 
nipple  and  extending  9^  in.  downwards,  or  to  2  in.  below  level  of  um- 
bilicus.    Portion  of   liver   below   ribs   causes   a   distinct   bulging   of 

1  Tlie  pre}>fir;if,ion  is  in  th(^  museum  of  Middlespx  Hospital.  In  the  museum  of  St. 
Bartholomew'H  IloHpifal  is  a  8p(!eimL-n  (xix,  12)  of  liydatid  tumour  of  ripht  lolie  of 
liver  openinip;  into  bilc-iiuct,  wliich  is  blocked  up  by  lijdatids,  one  of  ■which  projects 
from  the  orifice  of  the  duct  into  duudenum,  as  above. 


LECT.  m.  HYDATID    TUMOUR.  I  I  5 

abdominal  parietes ;  its  surface  firm,  smooth.,  and  somewhat  tender. 
Left  lobe  of  liver  not  enlarged,  the  tumour  turning  abruptly  upwards 
at  umbilicus  towards  ensiform  cartilage,  No  induration  of  integu- 
ments around  umbilicus ;  no  ascites  ;  no  enlargement  of  abdominal 
veins  ;  splenic  dulness  not  increased  ;  no  sign  of  any  bowel  in  front  of 
tumour  and  distinct  tympanitic  percussion  behind  it.  Thoracic  organs 
healthy ;  resp.  20;  pulse  ranges  from  92  to  128,  and  temp,  from  97°  to 
100°.  Urine  retained,  or  passed  involuntarily,  1017,  contains  much 
bile-pigment  and  lithates  and  ^  albumen,  and  also  a  few  blood-cor- 
puscles and  epithelial  scales,  but  no  leucin  or  tyrosin.  Occasionally 
delirious,  and  mind  at  all  times  so  confused  that  it  is  impossible  to 
obtain  a  clear  account  of  her  illness. 

On  N'ov.  17  patient  had  rather  a  severe  attack  of  diarrhoea,  wbich 
lasted  for  about  three  days,  during  which  sh.e  passed  in  bed  numerous 
black,  liquid,  very  oifensive  motions,  which,  unfortunately  were  not 
carefully  examined.  On  Nov.  20  diarrhoea  had  ceased,  and  motions 
were  again  noted  as  light  and  solid.  On  Nov.  21  patient  appeared 
slightly  better  and  her  mind  was  clearer  ;  but  after  this  h.er  pros- 
tration increased  and  she  gradually  passed  into  a  state  of  stupor,  with 
dry  tongue  and  sordes  about  mouth,  which,  continued  until  death  on 
Nov.  25. 

Autopsy. — Right  lobe  of  liver  greatly  elongated,  extending  9  in. 
below  level  of  lower  end  of  sternum.  Projecting  from  its  anterior 
margin,  and  looking  very  much  like  gall-bladder,  was  a  hydatid  cyst, 
about  2  in.  in  diameter.  Another  cyst,  larger  than  a  man's  fist,  was 
embedded  in  substance  of  right  lobe,  projecting  slightly  from  upper  and 
anterior  surface.  This  cyst  contained  a  thin  purulent-looking  fluid 
coloured  with  bile  and  several  smaller  cysts,  and  the  cavity  in  which  it 
was  lodged  communicated  with  the  bile-ducts.  A  large  mass  of  hydatid 
membrane  blocked  up  the  termination  of  common  duct,  and  partially 
projected  into  duodenum.  The  common,  cystic,  and  hepatic  ducts 
were  all  greatly  dilated,  and  in  interior  of  liver  ducts  were  also  dilated 
into  cyst-like  cavities  filled  with  opaque  orange-coloured  fluid.  Gall- 
bladder contained  three  calculi  and  several  small  hydatid  cysts. 
Kidneys  congested  and  stained  with  bile,  but  otherwise  healthy. 
Stomach,  spleen,  heart,  and  brain  normal.  Lower  lobe  of  right  lung  ad- 
herent to  diaphragm,  much  congested,  and  containing  several  solid 
blocks,  one  hemorrhagic,  and  the  others  dark  red  with  a  drop  or  two 
of  dirty  pus  in  interior.  Lower  lobe  of  left  lung  congested,  but  free 
from  blocks. 

The  following  case,  XXXIV.,  is  remarkable  no  less  for  the 
fact  that  the  patient  recovered  after  discharging  the  contents 
of  a  large  hydatid  of  the  liver  through  the  bile-duct  into  the 
bowel,  than  for  the  extraordinary  manner  in  which  death 
ultimately  occurred. 

I  2 


Il6  ENLAEGEMENTS    OF    THE    LIVEE.  lect.  iii. 

Case  XXXIV. — Hydatid  Tumour  of  Liver,  bursting  into  Bile-duct — 
Jaundice — Discliar ge  of  numerous  Hydatid  Membranes  per  Anmn — 
Recovery — Attacks  of  Biliary  Colic  from  passage  of  Cysts  remaining 
in  Liver  through  Bile-duct — Rupture  of  old  Adhesions  of  Liver  during 
act  of  Vomiting— Peritonitis — Death. 

On  October  29,  1861,  I  was  consulted  by  Mr.  G.  W ,  a  solicitor, 

aged  63.  For  some  weeks  lie  had  been  suffering  from  flatulence  and  a 
feeling  of  tigbtness  and  oppression  after  meals,  and  three  days  before 
he  had  been  attacked  with  severe  pains  in  abdomen,  resembling  colic. 
The  countenance  was  somewhat  sallow  ;  motions  were  pale,  but  con- 
tained bile  ;  no  bile  in  urine,  which  was  scanty  and  dark,  having  a 
specific  gravity  of  1027,  and  depositing  much  lithic  acid.  Vertical  he- 
patic dulness  in  the  right  mammary  line  extended  about  an  inch  below 
edge  of  ribs,  and  all  along  right  hypochondrium  there  was  slight  ten- 
derness on  pressure.  Pulse  64.  His  digestion  had  always  been  good, 
except  once,  about  seven  years  before,  when  he  had  several  attacks  of 
colicky  pain  in  abdomen,  similar  to  those  from  which  he  had  recently 
suffered.  The  remedies  prescribed  by  myself,  and  afterwards  by  Sir 
Thomas  Watson,  who  met  me  in  consultation,  failed  to  give  relief. 

On  Nov.  24  patient  had  an  attack  of  vomiting,  followed  by  an 
atro-ravation  of  the  dyspeptic  symptoms,  and  by  increased  tenderness 
in  right  hypochondrium. 

On  Dec.  6  he  was  much  worse.  The  tenderness  in  right  side  had 
increased  greatly,  and  there  was  also  constant  pain  there,  which  became 
very  acute  when  he  took  a  long  breath  or  coughed.  Tongue  furred  and 
moist ;  bowels  very  costive ;  considerable  tympanitic  distension  of 
abdomen,  and  increased  sallowness,  but  no  sickness.  Pulse  88  ;  respi- 
rations 30,  and  thoracic.  Fifteen  leeches  were  applied  to  seat  of  pain ; 
twelve  more  on  Dec.  8,  and  eight  more  on  Dec.  10,  with  poultices  in 
the  intervals,  and  bowels  were  kept  open  by  castor-oil  and  turpentine 
enemata. 

On  Dec.  12  pain  was  much  less,  but  there  was  still  considerable 
tenderness  and  a  stitch  in  right  side  on  taking  a  breath  or  coughing. 
Countenance  very  sallow,  but  no  decided  yellowness  of  conjunctiva, 
and  motions,  though  pale,  contained  bile.  Vertical  hepatic  dulness  in 
right  mammary  line  5  in.  Nothing  like  a  defined  tumour  could 
be  felt,  and  there  was  no  bulging  of  ribs.  Breathing  at  base  of  right 
lung  normal.     Pulse  88. 

On  Dec.  16  and  17  patient  passed,  for  first  time,  several  hydatid 
cysts  in  a  bilious  motion. 

On  Dec.  18  he  was  much  Avorse.  There  was  decided  jaundice  of 
integuments;  urine  loaded  wilh  bile-pigment,  and  not  a  trace  of  bile 
or  of  hydatid  membranes  in  motions.  Constant  pain  in  right  side,  in 
addition  to  occasional  jiaroxysms,  like  colic ;  lips  parched ;  tongue 
furred  ;  much  perspiration  in  night,  and  great  pro.^^tration.    Pulse  100. 


LECT.  III.  HYDATID    TUMOUR.  I  I  / 

Treafcment  consisted  in  constant  application  of  poultices  to  side,  and  in 
administration  of  blue  pill  and  opium. 

Dec.  19. — Is  mncli  easier.  Has  passed  a  large  quantity  of  hydatid 
vesicles,  from  a  pin's  head  to  an  orange  in  size,  per  anum.  Skin  and 
urine  still  jaundiced,  and  no  bile  in  stools. 

20. — Faeces  to-day  are  tinged  with  bile,  and  still  contain  numerous 
hydatid  cysts. 

21. — Jaundice  almost  gone.  Motions  still  contain  hydatids  and 
abundance  of  bile.  Below  and  to  left  of  right  nipple,  tympanitic  per- 
cussion over  a  space  the  size  of  a  crown-piece.  Both  above  and  below 
this  there  is  hepatic  dulness.  Pulse  88;  pain  much  less;  tongue 
cleaning. 

The  patient  continued  to  pass  a  few  hydatid  vesicles  with  each 
motion  up  to  Dec.  31,  and  the  tympanitic  percussion  sound  above 
noted  remained  a  few  days  later  than  this.  He  had  occasional  sharp, 
but  temporary,  attacks  of  pain  in  abdomen,  resembhng  colic.  On  Jan. 
6,  1862,  he  was  quite  convalescent.  Pulse  72.  The  tympanitic  sound 
noted  above  could  no  longer  be  distinguished,  and  upper  border  of 
hepatic  dulness  was  an  inch  lower  than  before.     At  end  of  Jan.   Mr. 

W was  able  to  drive  out ;  and  on  Feb.  19  he  went  to  Ventnor  for 

change  of  air,  returning  to  London  on  March  11. 

Once,  while  at  Ventnor,  he  had  a  severe  attack  of  colicky  pain 
lasting  for  an  hour  and  a  half,  and  '  bending  him  up  double.'  He  had 
a  similar  attack,  but  less  severe,  a  few  days  after  his  return  to  London. 
Both  attacks  were  unaccompanied  by  vomiting.  Every  day  he  gained 
strength,  and  on  his  return  to  town  he  was  able  to  resume  his 
business.  On  April  2  he  went  down  to  Essex  on  business.  He  walked 
about  the  country  several  miles  every  day,  feeling  none  the  worse,  and 
returned  to  town  on  April  6. 

On  April  8  he  went  to  his  business  as  usual,  and  walked  several 
miles.  Shortly  after  dinner,  about  7  p.m.,  he  was  suddenly  seized  with 
severe  pain  in  abdomen,  which  returned  in  paroxysms,  and  this  time 
was  accompanied  by  vomiting.  There  was  slight  tenderness  at  epi- 
gastrium, but  no  jaundice.  Pulse  only  84.  Repeated  doses  of  opium 
and  chloric  ether  were  prescribed,  and  poultices  were  kept  constantly 
applied  over  abdomen. 

On  following  day,  the  paroxysms  of  pain  had  ceased,  but  there  was 
more  tenderness  at  epigastrium  and  in  right  hypochondrium,  and  con- 
siderable pain  when  he  coughed  or  moved.  The  vomiting  had  not 
quite  ceased.  There  was  slight  sallowness,  but  stools  contained  bile. 
Pulse  86.  Ten  leeches  were  ordered  to  be  applied  to  side,  and  the 
poultices  and  opiates  were  to  be  continued. 

The  patient  did  not  apply  the  leeches,  as  he  felt  better.  In  the 
afternoon,  he  had  two  severe  attacks  of  rigors,  after  which  he  felt  so 
much  better  and  free  from  pain  that  he  thought  it  unnecessar  to  send 
for  me. 


I  1 8  ENLARGEMENTS    OF   THE    LIVEK.  lect.  hi. 

On  the  morning  of  April  10  he  said  that  he  felt  so  much  better  that 
he  had  eaten  a  good  breakfast,  and  he  wished  to  get  up  and  go  down 
stairs  ;  but  he  was  in  a  state  of  extreme  prostration,  and  evidently 
sinking.  The  pulse  was  120  at  the  elbows,  and  imperceptible  at  the 
wrists.  The  sickness  had  ceased,  but  the  features  were  pinched,  and 
the  skin  was  cold  and  covered  with  clammy  sweat.  He  gradually  sank, 
and  died  at  8  p.m. 

Autoj)sy. — Abdomen  only  was  examined.  On  opening  this  cavity 
intestines  appeared  healthy,  but  distended  with  gas.  No  exudation  or 
increased  vascularity  in  general  cavity  of  peritoneum.  Large  intes- 
tines contained  a  quantity  of  pulpy  material  of  colour  of  cream,  and 
without  any  tinge  of  bile.     Small  intestines  contained  bile. 

Left  lobe  of  liver  was  healthy  and  non-adherent.  Both  the  upper 
and  under  surfaces  of  right  lobe  were  firmly  adherent  to  adjoining 
parts.  Near  right  edge  of  liver  a  few  of  the  bands  of  adhesion  fasten- 
ing it  to  ribs  appeared  to  be  ruptured,  and  at  this  point  there  was  a 
patch  of  recent  lymph  not  larger  than  a  square  inch,  with  slightly  in- 
creased vascularity  round  about.  In  substance  of  right  lobe  was  an 
irregularly-shaped,  collapsed  cavity,  the  size  of  a  large  orange  ;  walls 
of  this  cavity  were  partly  formed  by  ribs  and  surrounding  adhesions  ; 
its  inner  surface  consisted  of  indurated  hepatic  tissue,  presenting  a 
shreddy  appearance,  and  not  lined  by  hydatid  membrane.  The  cavity 
was  almost  empty  ;  but  it  contained  four  or  five  collapsed  hydatid 
vesicles  about  size  of  a  shilling.  Communicating  with  it  was  a  greatly 
dilated  bile-duct,  passing  directly  on  to  the  common  duct.  The  entire 
duct,  from  the  cavity  to  the  orifice  in  duodenum,  was  large  enough  to 
admit  tip  of  little  finger.'  Fui-ther  back,  in  right  lobe,  and  quite  dis- 
tinct from  cavity  now  described,  was  another,  about  size  of  a  plum, 
which  was  lined  by  an  obsolete  and  cribriform  hydatid  cyst,  presenting 
a  tough,  opaque  yellow  appearance.  The  contents  of  this  cavity  had 
escaped  during  the  hurried  division  of  the  liver.  (This  tumour  may 
have  been  the  source  of  the  symptoms  from  which  patient  had  suffered 
seven  years  before  his  death). 

Case  XXXV.,  like  Case  XXV.,  illustrates  the  good  eflFects  of 
antiseptic  treatment  after  the  free  opening  of  a  large  hydatid 
which  had  undergone  suppuration. 

Case  XXXV. — Suppurating  Hydatid  of  lAver.     Free  Incision — 

Itecovery. 

Miss  M ,  aged  24,   consulted   me  on   Nov.   24,   1869.      She 

stated  that  for  two  years  she  had  noticed  a  bulging  of  the  lower  right 
libs.  This  had  come  on  without  pain,  and  had  not  increased  much 
since  it  had  been  first  observed.     The  bulging  was  quite  obvious:   the 

'  Tho  preparation  is  in  museum  of  Middlesex  Hospital. 


LECT.  III.  HYDATID    TUMOUR.  I  I9 

girth  of  the  right  side  of  the  chest  below  the  breast  was  15^  in.,  of 
the  left  13^  in.  The  hepatic  dulness  in  the  right  nipple  line  ex- 
tended from  the  nipple  8  in.  downwards ;  it  did  not  rise  too  high 
at  the  back,  and  its  upper  border  was  arched.  The  intercostal  spaces 
over  the  bulging  were  obliterated,  but  nothing  like  fluctuation  could 
be  made  out.  There  was  no  tenderness  on  pressure,  and  the  general 
health  was  good. 

I  saw  nothing  more  of  the  patient  until  Feb.  4,  1873,  when  she 
stated  that  for  two  months  she  had  been  liable  to  attacks  of  severe 
pain,  shooting  from  the  back  to  the  front  of  the  swelling,  which  made 
her  scream  and  prevented  sleep.  These  attacks  were  very  apt  to  come 
on  when  she  lay  down.  She  had  also  uneasiness  in  the  stomach  after 
food,  and  was  losing  flesh.  The  swelling  had  increased  especially  in  an 
upward  direction.  Below  the  breast  the  girth  on  the  right  side  was  16  in. 
and  on  the  left  14|  in.  The  hepatic  dulness  in  front  rose  to  1^  in.  above 
the  nipple,  and  from  this  extended  9|^in.  downwards,  to  3  in.  below  the 
ribs  ;  posteriorly  also  the  hepatic  dulness  rose  an  inch  or  two  above  its 
normal  level,  and  air  entered  imperfectly  into  lower  lobe  of  right  lung. 
No  perceptible  fluctuation,  Pnlse  108,  temperature  somewhat  elevated. 
I  expressed  the  opinion  that  the  tumour  was  hydatid,  and  advised  that  an 
exploratory  puncture  should  be  made  into  it.  Sir  W.  Jenner,  who  saw 
the  patient  with  me  on  Feb.  22,  coincided  in  this  opinion  and  advice. 
On  Feb.  24  the  swelling  was  punctured  between  the  sixth  and  seventh 
right  ribs  in  front ;  3  drachms  of  pus  escaped  ;  the  opening  was  closed, 
and  on  Feb.  26  a  free  incision  was  made  at  the  same  spot  by  Mr.  De 
Morgan,  and  4  pints  of  pus  containing  numerous  large  hydatid  cysts 
were  evacuated.  The  cavity  was  washed  out  with  a  solution  of  chloride 
of  zinc  (20  gr.  to  §j),  and  a  piece  of  elastic  tube  was  left  in  the 
open  Id  g,  through  which  a  weak  solution  of  carbolic  acid  was  daily  in- 
jected, and  external  opening  was  covered  with  carded  oakum.  The 
severe  pain  from  which  the  patient  had  previously  suffered  was  at  once 
relieved.  Much  pus  and  hydatids  continued  to  be  discharged  until 
March  17,  when  what  appeared  to  be  the  parent  sac  escaped.  After  this 
the  discharge  rapidly  diminished,  and  the  patient  began  to  gain  flesh. 
On  April  28  the  tube  was  removed,  and  soon  after  opening  closed. 

On  April  8,  1875,  patient  was  in  enjoyment  of  excellent  health. 

In  Case  XXXYI.  tlie  hydatid  tumour  not  only  suppurated, 
but  induced  pyaemia,  with  secondary  deposits  of  pus  throughout 
the  liver. 

Case  XXXVI, — Supjpurating  Hydatid  Tumour  of  Liver — Pyoemia,  with 
secondary  Deposits  of  Pus. 

Thomas   B ,  aged  35,  was  admitted  into  the   London  Fever 

Hosp.  on  Jan.  20,  1866.  He  had  lived  for  twenty  years  in  Tasmania, 
but  for  the  last  four  jears  in  England,     His  previous  health  had  always 


120  ENLAEGEMENTS    OF    THE    LIVER.  lect.  iu. 

been  srood.  His  illness  commenced  five  weeks  before  admission  with 
severe  pain  in  right  side,  followed  three  weeks  later  by  jaundice  and 
diarrhoea.  When  seized  with  the  pain,  he  first  noticed  a  swelling  in 
right  side  ;  but  this  was  as  large  then  as  at  time  of  admission.  Patient 
was  emaciated  and  jaundiced,  and  liver  was  much  enlarged,  vertical 
dulness  in  right  mammary  line  being  eight  inches.  The  portion  of 
Jiver  projecting  below  right  ribs  was  smooth,  painless,  elastic,  and 
almost  fluctuating,  but  yielded  nothing  like  '  hydatid  vibration.' 
Moderate  ascites.  Pulse  9G  ;  tongue  moist  and  red  ;  no  appetite  ;  six 
or  seven  liquid  stools  daily,  containing  little  or  no  bile.  Considerable 
sweating  at  night.  Three  or  four  days  after  admission,  irregular  attacks 
of  rigors  set  in  ;  diarrhoea  continued  ;  emaciation  and  perspirations  in- 
creased ;  tongue  became  dry  and  brown  ;  and  on  Feb.  22  patient  died. 
On  two  occasions  (Jan.  31  and  Feb  7)  an  exploratory  puncture  was 
made  into  tumour.  On  first  occasion  nothing  came  away,  owing  to 
trocar  being  too  short ;  on  second  occasion  about  six  ounces  of  thin 
purulent  bilious  fluid  were  drawn  ofi*,  which,  unfortunately,  was  not 
submitted  to  microscopic  examination.  No  bad  consequence  appeared 
to  follow  either  operation. 

At  the  autopsy,  a  hydatid  cyst,  as  large  as  a  child's  head,  and  full 
of  pus  and  secondary  hydatids,  was  found  projecting  from  under  sur- 
face of  Hver,  compressing  portal  vein  and  bile-ducts.  The  liver  was 
studded  with  numerous  small  abscesses,  and  its  outer  surface  was 
coated  with  recent  lymph.  Traces  of  the  punctures  were  discovered 
with  difiiculty,  and  there  was  no  evidence  of  increased  inflammatory 
action  in  their  neighbourhood. 

In  the  following  case  tlie  suppuration  of  a  hydatid  appears 
to  have  induced  pyaemia,  with  secondary  gangrenous  abscesses 
in  the  liver.  The  anatomical  characters  of  the  liver  agreed 
with  those  of  'gangrene  of  the  liver'  as  described  by  Roki- 
tansky.'  This  disease,  however,  is  so  rare  that  experienced 
observers  have  denied  its  occurrence,  and  !Frerichs  makes  no 
mention  of  it.  Even  Rokitansky  had  met  with  only  one  ex- 
ample, and  there  it  was  associated  with  pulmonary  gangrene. 
Budd  reports  one  case,  and  quotes  another  from  Andral.^  Con- 
sidering the  rarity  of  such  cases,  the  remarkably  fetid  odour 
observed  during  life  is  of  clinical  interest. 

Case  XXXVII. — Suiiptiratlng  Hydatid — Fycemia,  with  secondary 
Gangrenous  Abscesses  in  Liver. 

A  man,  aged  27,  was  adm.  into  London  Fever  Hospital  under  my 
care,  Feb.   23,  18(57.     He  was  so  prostrate  that  he  could  give  little 

«  Path.  Anat.  Syd.  Soc.  Trans,  vol.  ii.  p.  136. 
«  Budd,  op.  cit.  3rd  ed.  p.  129. 


LECT.  III.  HYDATID    TUMOUE.  121 

account  of  himself,  and  all  that  could  be  ascertained  was  that  he  had 
been  a  soldier  in  the  West  Indies  for  about  seven  years,  but  that  his 
health  had  been  good  until  about  a  month  before  admission,  when  he 
was  seized  with  pain  in  epigastrium  and  right  hypochondrium,  with 
nausea  and  vomiting,  and  about  sarae  time  he  first  noticed  a  tumour 
below  right  ribs,  pain  in  which  made  it  difficult  for  him  to  button  his 
tunic  over  it.  On  admission  he  lay  on  his  back,  with  his  legs  drawn 
up  ;  abdomen  full  and  tender  all  over  ;  friction  heard  distinctly  over 
liver,  which  appeared  large,  extending  downwards  to  crest  of  ilium, 
and  upwards  to  lower  border  of  third  rib.  Tongue  dry  and  brown ; 
frequent  vomiting ;  but  no  jaundice,  and  bowels  stated  to  be  regular. 
Splenic  dulness  increased.  Pulse  132  and  feeble  ;  heart's  sounds  normal ; 
i-espirations  quick  and  thoracic ;  dulness  on  percussion  over  back  of 
right  lung,  and  moist  sounds  heard  over  greater  part  of  both  lungs. 
Skin  hot,  face  pale  :  features  pinched. 

On  following  morning  prostration  had  increased,  and,  in  addition, 
there  was  noted  slight  jaundice  of  conjunctivas,  and  a  peculiar,  very 
fetid  odour — sui  generis,  which  appeared  to  proceed  from  entire  body, 
and  not  from  breath  in  particular.  This  was  noted  in  case-book  before 
patient's  death,  which  took  place  on  same  day. 

On  post-mortem  examination,  which  was  made  on  day  after  death, 
considerable  evidence  of  recent  peritonitis,  particularly  in  neighbour- 
hood of  the  liver.  Projecting  from  under  surface  of  right  lobe  of  liver, 
and  but  slightly  embedded  in  it,  was  a  hydatid  cyst,  larger  than  a  cocoa- 
nut.  The  wall  of  the  parasite  was  opaque,  tough,  and  cribriform, 
from  presence  of  numerous  large  openings,  and  its  interior  was  filled 
with  dirty  brown  purulent  fluid,  having  a  very  ofiensive  odour.  En- 
tire liver  studded  with  numerous  softened  masses  from  the  size  of  a 
nut  up  to  that  of  a  small  orange,  in  which  hepatic  tissue  was  softened, 
and  consisted  of  a  spongy  material,  corresponding  to  the  fibrous  stroma 
and  vessels,  saturated  with  a  greenish,  extremely  fetid,  pulpy  fluid. 
Embedded  in  substance  of  liver,  near  anterior  edge  of  right  lobe,  was 
a  healthy  hydatid  cyst,  about  the  size  of  a  chestnut,  containing  clear 
fluid  and  ecchinococci.  Lungs  congested,  but  nowhere  inflamed  or 
gangrenous. 

In  the  following  case  the  hydatid  tumour  was  so  large  as  to 
almost  fill  the  abdominal  cavity,  and  bile  had  entered  the  cyst. 
The  real  nature  of  the  case  was  not  recognised  during  the 
patient's  life,  and  paracentesis  was  resorted  to  merely  as  a 
palliative  to  relieve  the  patient's  extreme  distress,  and  with  no 
idea  of  effecting  a  cure. 


122  ENLAEGEMENTS   OP   THE    LIVEK.  iect.  in. 

Case  XXXVIII. — Enormous  Hydatid  Cyst  of  Liver,  passing  down  through 
Foramen  of  Winslow,  and  filling  almost  whole  of  Abdominal  Cavity — 
Paracentesis — Pleurisy — Tubercle  of  Lungs — Death  from  Exhaustion. 

Elizabeth  C ,  aged  15,  adm.  into  Middle.sex  Hosp.  under  Dr. 

Greenhow,  August  26,  1862.  She  had  been  a  very  healthy  infant,  but 
at  ao-e  of  3  she  had  a  severe  fall  on  her  right  side,  and  since  then  she  had 
never  been  well.  For  nine  or  ten  years  a  swelling  had  been  observed 
in  rio"ht  side  of  abdomen.  Three  years  before  admission  she  had  been 
a  patient  in  a  London  hospital,  but  she  bad  left  on  account  of  some 
operation  having  been  proposed.  The  tumour  increased  gradually  in 
size  without  causing  pain,  while  at  sa.nie  time  patient  became  thin  and 
weak.  Four  weeks  before  admission  she  had  been  attacked  with 
scarlatina,  and  during  convalescence  or  for  the  last  few  days  before 
admission,  a  very  rapid  increase  had  taken  place  in  size  of  tumour, 
and  there  had  been  occasional  pain  in  abdomen.  At  time  of  admission, 
face  and  extremities  were  greatly  emaciated ;  countenance  had  a 
haggard,  anxious  expression,  and  conjunctivae  were  slightly  tinged 
yellow.  Abdomen  enormously  enlarged,  and  yielded  distinct  fluctua- 
tion ;  but  the  remarkable  fact  was  that  there  was  resonance  on  per- 
cussion in  both  flanks,  as  well  as  in  epigastric  and  both  hypochondriac 
regions.  Patient  suffered  from  attacks  of  dyspnoea  and  of  severe 
pain  in  abdomen.  Pulse  100,  and  feeble  ;  no  abnormal  sound  with 
heart ;  respirations  hurried  and  thoracic  ;  appetite  good  ;  bowels  regu- 
lar ;  urine  very  scanty  and  loaded  with  bile.  On  Sept.  3  the  abdo- 
minal pain  and  dyspnoea  had  become  so  distressing  that  the  operation 
of  paracentesis  abdominis  was  performed  as  a  palliative  measui'e,  and 
248  ounces  of  a  dirty  brownish  fluid  were  drawn  off.  The  fluid  was, 
unfortunately,  not  submitted  to  the  microscope  or  to  chemical  reagents. 
The  immediate  effect  of  operation  was  great  relief  to  the  pain  and 
dyspnoea ;  but  within  three  days  the  swelling  was  observed  to  be 
rapidly  increasing,  and  on  Sept.  26  its  dimensions  were  larger  than 
before  operation,  although  dyspnoea  was  not  nearly  so  urgent.  On 
following  day,  patient  died  from  exhaustion. 

Autopsy. — On  dividing  abdominal  parietes,  about  14  pints  of 
straw-coloured  serum  escaped.  Greater  part  of  abdominal  cavity,  as 
far  down  as  pubes,  was  lined  with  a  closely  adherent  gelatinous  mem- 
brane, forming  part  of  an  enormous  hydatid  cyst,  by  which  stomach  and 
intestines  were  pressed  up  closely  against  under  surface  of  diaphragm 
and  liver,  where  they  were  matted  together,  their  peritoneal  surface 
being  considerably  injected.  Floating  in  the  fluid,  in  the  large  abdo- 
minal cyst,  was  a  secondary  cyst  containing  about  a  pint  of  fluid  and 
what  appeared  to  be  the  debris  of  other  cysts.  Several  cysts  of 
smaller  size  were  likewise  found  in  cavity  of  the  large  sac.  On  trac- 
ing the  large  primary  cyst,  it  was  seen  to  be  continuous  with  a  cyst 
about  the  size  of  a  child's  head   projecting  from,  and  attached  ta 


LECT.  III.  HYDATID    TUMOUE.  1 23 

under  surface  of  liver.  The  two  cavities,  in  fact,  constituted  one  cyst, 
with  an  hour-glass  constriction,  the  channel  of  communication  being 
large  enough  to  admit  three  fingers,  and  apparently  corresponding  to 
foramen  of  Winslow.  Gall-bladder  compressed,  empty,  and  atrophied. 
Attached  to  anterior  border  of  left  lobe  of  liver,  by  a  thin  fibrous 
peduncle,  was  another  tumour  about  size  of  a  goose's  egg,  which,  on 
being  opened,  was  found  to  contain  a  crumpled-up  hydatid  cyst,  filled 
with  a  putty- like  material,  in  which  were  numerous  booklets  of  echino- 
cocci.  A  third  tumour  was  found  attached  to  upper  surface  of  right 
lobe  of  liver,  and  firmly  adherent  to  under  surface  of  diaphragm, 
which  was  pressed  up  into  cavity  of  right  pleura.  This  tumour  was 
lined  with  a  cyst,  containing  about  a  pint  of  straw-coloured  serum, 
and  inner  surface  of  which  was  studded  with  ecbinococci.  Right 
pleural  cavity  contained  about  a  pint  of  semi-purulent  fluid,  and  op- 
posed surfaces  of  pleura,  at  base  of  right  lung,  were  coated  with  a 
deposit  of  recent  semi-organised  lymph.  Both  pleural  cavities  were 
much  diminished  in  calibre  by  elevation  of  diaphi-agm,  and  both  lungs 
contained  numerous  scattered  miliary  tubercles.  Heart  small,  but, 
in  other  respects,  normal.  Spleen  pale  and  shrunken.  Kidneys  lai'ge 
and  congested. 

In  th.e  next  three  cases  a  hydatid  of  the  liver  proved  fatal 
by  opening  into  the  pleura  or  lung. 

The  first  case,  which  occurred  while  I  was  pathologist  to 
the  Middlesex  Hospital,  illustrates  the  absence  of  all  symptoms 
in  a  large  hydatid  tumour  of  the  liver  prior  to  its  bursting  into  the 
pleura,  and  also  the  difficulty  in  diagnosis  likely  to  arise  from  the 
CO- existence  of  empyema  with  hydatid  enlargement  of  the  liver. 

Case  XXXIX. — Hydatid  Tiimour  of  Liver,  hursting  into  Right  Pleura — 
Empyema — Death. 

Louisa  R ,   aged   17,  adm.  into  Middlesex  Hosp.   under  Dr. 

H.  Thompson, -March  23,  18G1.  She  was  a  servant,  and  until  a  fort- 
night before  she  had  continued  at  her  work,  enjoying  good  health, 
and  not  sufiering  any  pain  or  uneasiness.  She  was  then  suddenly 
seized  with  acute  pain  in  upper  part  of  abdomen  and  on  both  sides  of 
chest,  which  was  increased  by  inspiration,  and  was  accompanied  by 
cough,  dyspnoea,  febrile  symptoms,  and  great  prostration.  On  admis- 
sion, pulse  112,  small  and  weak.  Slight  cough.  Dulness  and  ab- 
sence of  breathing  over  whole  of  right  side  of  chest,  except  in  infra- 
clavicular space.  There  was  likewise  dulness,  with  feeble  breathing, 
at  base  of  left  lung.  Hepatic  dulness  in  right  mammary  line  extended 
nearly  four  inches  below  margin  of  ribs.  No  jaundice  and  no  ascites  ; 
but  urine  contained  albumen.  Hectic  fever,  with  great  prostration, 
set  in,  and  death  occurred  on  April  8,  one  month  after  first  symptom 
of  illness. 


124  ENLARGEMENTS    OF    THE    LIVER.  lect.  hi. 

Aiifojjsij. — Heart  normal.  Left  lung  firmly  and  Tiniversally  ad- 
herent :  its  lower  lobe  hyperffimic,  and  near  base  its  tissue  sank  in 
water  ;  but  it  was  not  granular  on  section,  and  it  was  unusually  firm 
and  tenacious.  Right  pleural  cavity  filled  with  pus,  floating  in  which 
were  innumerable  hydatid  vesicles,  from  size  of  a  pin's  head  to  that  of 
an  orange.  Right  lung  completely  collapsed  and  carnified,  except  at 
apex,  which  contained  a  little  air.  Liver  much  depressed,  its  lower 
margin  reaching  to  more  than  half-way  between  umbilicus  and  pubes. 
Projecting  from  posterior  margin  of  right  lobe  was  a  cyst  as  large  as 
a  child's  head,  and  firmly  connected  to  diaphragm  ;  liver  not  adherent 
at  any  other  part  of  its  surface.  At  upper  part  of  cyst  there  was  a 
rupture  through  diaphragm,  measuring  one  inch  and  a  half  in  dia- 
meter, by  which  cyst  communicated  with  right  pleura.  The  interior  of 
cyst  was  lined  with  a  hydatid  membrane  ;  its  cavity  was  filled  with  pus 
and  vesicles.  A  large  number  of  the  vesicles  were  examined  with  micro- 
scope, but  no  echinococcus  or  booklet  could  be  discovered.  No  other 
hydatid  tumour  either  in  liver  or  ia  any  organ  of  body.  Pelvis  and 
calices  of  right  kidney  and  upper  part  of  right  ureter  dilated,  appa- 
rently owing  to  pressure  below  of  the  displaced  liver  ;  secreting  tissue 
of  right  kidney  much  atrophied  ;  left  kidney  normal. 

Case  XL. — Hydatid  Tumour  of  Liver,  opening  into  Bdght  Pleura — 
Emjnjem  a —  Pericard it  is . 

George  K — — ,  aged  54,  a  gardener,  of  sober  habits,  adm.  into 
Middlesex  Hosp.  under  Dr.  F.  Hawkins,  April  25,  1854.  He  had  al- 
ways enjoyed  good  health  until  four  months  before  admission,  when  he 
was  suddenly  seized  with  pain  all  over  abdomen,  but  particularl}^  in 
right  hypochondrium,  and  extending  thence  to  right  shoulder.  About 
same  time  he  became  slightly  jaundiced.  The  pain  and  jaundice  con- 
tinued ;  and  at  time  patient  came  under  observation  he  was  very 
weak  and  emaciated,  and  suffered  from  incessant  cough.  Liver  much 
enlarged,  extending  down  to  umbilicus.  Considerable  bulging  of 
right  side  of  chest,  which  was  universally  dull  on  percussion,  and  de- 
void of  respiratory  murmur,  except  at  upper  and  back  part  close  to 
spine.     Patient  gradually  sank,  and  died  on  May  10. 

Autnjisy. — Right  pleural  cavity  was  filled  with  a  yellowish,  turbid, 
semi-purulent  fluid  containing  masses  of  a  gelatinous  substance,  which 
proved  to  be  hydatid  cysts.  Right  lung  compressed  and  flattened 
against  vertebral  column,  and  at  its  base  was  firmly  bound  by  adhe- 
sions to  diaphragm.  It  did  not  crepitate  in  the  least  ;  it  sank  in 
water,  and  was  completely  caniiCed.  Liver  enormously  enlarged,  ex- 
tending down  as  far  as  umbilicus,  and  weighing  90  ounces  ;  it  was 
firmly  adherent  to  diaphragm.  In  posterior  part  of  right  lobe  was  a 
cavity  as  large  as  a  swan's  egg,  lined  with  a  hydatid  cyst,  and  con- 
taining similar  cysts  in  its  interior.     Upper  wall  of  this  cavity  was 


LECT.  in.  HYDATID    TUMOUE.  I25 

formed  by  tlie  diapliragm,  and  here  there  was  a  large  opening  by 
which  the  cavity  in  the  liver  communicated  with  right  pleura.  The 
liver  was  much  congested.  Pericardium  glued  to  heart  by  recent  soft 
adhesions.     Left  lung,  spleen,  and  kidneys  healthy. 

Case  XLI. —  Old  Hydatid  (?)  of  Liver,   commuwicaUng  with  Base  of 
Right  Lung — Lobular  Fneiwionia  and  Gangrene  of  Lung. 

Robert   J ,    aged    72,   was   sent   to   London   Fever   Hospital, 

August  21,  1864,  as  a  case  of  '  fever.'  On  examination,  he  was  found 
not  to  be  suffering  from  any  form  of  idiopathic  fever.  The  man 
stated  that  he  had  had  a  bad  cough  for  two  months,  and  had  kept  his 
bed  for  two  days.  His  breath  had  a  most  decidedly  gangrenous  odour  • 
sputa  of  a  dirty  greenish  muco-purulent  character,  and  extremely 
fetid.  Dry  bronchial  rales  audible  over  chesit,  and  at  right  base  slight 
duhiess,  with  increased  vocal  resonance,  and  large  moist  rales,  but 
nothing  approaching  to  cavernous  breathing.  Pulse  96  ;  respirations 
36.  IS'o  change  took  place  in  physical  signs  of  chest ;  but  tongue  be- 
came dry  and  brown;  diarrhoea  supervened;  and  patient  gradually 
lost  flesh  and  strength  until  death  on  Sept.  11. 

On  post-mortem  examination,  there  was  lobular  pneumonia  of 
lower  lobe  of  right  lung,  and  quite  at  base  a  gangrenous  portion 
about  size  of  an  orange.  Lung  was  here  firmly  adherent  to  diaphragm 
and  diaphragm  to  liver,  and  the  broken-down  tissue  of  the  gangrenous 
lung  communicated  by  several  openings  with  a  cavity  in  upper  part 
^f  right  lobe  of  the  Hyer,  measuring  about  three  inches  in  diameter. 
This  cavity  contained  much  calcareous  matter  and  a  quantity  of  a 
dirty  greyish,  very  fetid,  pultaceous  substance.  On  careful  examina- 
tion, no  booklets  of  echinococci  could  be  discovered.  Rest  of  Hver 
and  the  intestines  healthy. 

The  absence  of  booklets  may  be  thought  to  negative  the  opinion 
that  the  tumour  of  the  liver  was  originally  an  hydatid.  But  though 
these  booklets  resist  the  changes  which  occur  in  the  interior  of  the 
body  for  an  indefinite  period,  they  do  not  resist  the  putrefactive 
changes  resulting  from  exposure  to  atmospheric  air,  and  such  expo- 
sure must  have  existed  here  for  many  weeks  before  death.  An  obso- 
lete abscess  is  the  only  other  lesion  that  could  have  produced  the 
appearances  described,  but  the  man  had  never  suffered  from  the  sym- 
ptoms of  abscess  of  the  liver. 

In  the  two  following  cases,  and  also  in  Case  XXXIX.,  the 
tumour  appeared  to  compress  the  ureters. 

Case  XLII. — Hydatid  of  Liver — Pyelitis — Pus  in  Urine — Sudden  Death. 

Ellen  C ,  aged  21,  came  under  ray  care  as  an  out-patient  at  Mid- 
dlesex Hospital,  in  April  1861.     She  stated  that  for  about  eighteen 


126  ENLARGEMENTS    OF    THE    LIVER.  lect.  hi. 

months  she  had  been  getting  very  weak  and  losing  flesh,  and  that 
latterly  she  had  suffered  from  dyspnoea.  She  had  no  cough,  but  lier 
father  had  died  of  consumption.  She  had  also  suffered  from  irregular 
menstruation  and  leucorrhoea.  On  examining  chest,  there  was  found 
to  be  a  bulging  of  right  side,  commencing  at  upper  border  of  fifth  rib, 
attaining  its  maximum  at  false  ribs,  and  then  as  gradually  declining. 
Hepatic  dulness  in  right  mammary  line  extended  for  3  in.  below 
margin  of  ribs,  and  its  total  length  was  6^  inches.  The  bulging  below 
ribs  occupied  right  hypochondrium  and  epigastrium,  and  extended 
over  to  left  hypochondrium  ;  it  was  slightly  tender,  and  presented  an 
elastic,  almost  fluctuating  consistence,  and  on  percussion  commu- 
nicated to  finger  the  peculiar  sensation  known  as  '  hydatid  vibration.' 
These  characters  were  most  marked  in  epigastrium.  Superficial  veins 
about  epigastrium  and  hj'pochondrium  much  enlarged.  Movements 
of  respiration  mainly  confined  to  left  side  of  chest.  On  right  side, 
respiratory  murmur  could  not  be  heard  below  fourth  rib  in  front,  or 
below  lower  angle  of  scapula  posteriorly.  Above  this  breathing 
was  harsh  and  expiration  prolonged.  On  left  side  dulness  and  ab- 
sence of  respiration  up  to  Avithin  half  an  inch  of  lower  angle  of  scapula. 
Patient  could  give  no  information  as  to  length  of  time  tumour  had 
existed.  In  fact,  she  was  quite  ignorant  of  existence  of  any  unusual 
swelling  until  it  was  pointed  out  to  her.  Her  complexion  was  slightly 
sallow,  but  she  had  never  suffered  from  jaundice  or  vomiting,  and  her 
bowels  were  regular ;  appetite  very  bad.  In  addition  to  tumour  on 
right  side,  a  painful  swelling,  apparently  the  displaced  left  lobe  of 
liver,  could  be  felt  in  left  lumbar  region  in  situation  of  kidney,  and 
there  was  a  copious  discharge  of  pus  in  urine. 

The  patient  remained  under  my  observation  for  nearly  twelve 
months.  The  dimensions  of  the  tumour  did  not  alter  much,  but,  on 
the  whole,  they  became  slightly  larger.  From  time  to  time  she 
suffered  severe  pain  in  swelling  in  left  lumbar  region.  At  these  times 
urine  was  clear,  or  almost  so,  and  relief  was  always  attended  with  a 
sensation  of  bursting  and  a  return  of  pus  in  large  quantity.  Urine 
was  repeatedly  examined  with  microscope,  but  no  pus,  casts,  or  trace 
of  echinococci  could  be  discovered. 

The  treatment — which  consisted  in  administration  of  tonics  and 
iodide  of  potassium,  and  external  application  of  iodine — failing  to  give 
relief,  patient  was  admitted  into  hospital  on  Jan.  14,  1862,  with  the 
object  of  having  a  puncture  made  into  the  tumour  in  right  hypochon- 
drium. After  remaining  in  hospital  for  six  weeks  she  refused  to  give 
her  consent,  and  was  discharged  at  her  own  request. 

I  did  not  sec  the  patient  after  this :  but  I  ascertained  that,  on 
Nov.  6,  18G3,  she  was  admitted  into  University  College  Hospital, 
under  care  of  Dr.  Hare,  to  whom  I  am  indebted  for  the  particulars 
noted  while  she  was  under  his  observation.  Towards  the  end  of  18G2 
she  had  first  suffered  from  pain  in  region  of  tumour  in  right  hypo- 


LECT.  III.  HYDATID    TUMOUR,  127 

chondrinm.  The  pain  was  intermittent  in  its  character,  ceasing  after 
a  few  days.  For  this  she  had  been  treated  at  the  Female  Hospital  in 
Soho  Square.  The  dimensions  of  tamonr  noted  in  University  College 
Hospital  showed  that  it  had  increased  considerably.  Although  right 
costal  angle  was  still  greater  than  left,  there  was  bulging  of  ribs  on 
both  sides  as  high  as  nipple,  and  dulness  on  percussion  up  to  third 
rib  on  right  side,  and  up  to  third  intercostal  space  on  left  side.  The 
heart  was  displaced  upwards,  its  apex  beating  in  third  left  intercostal 
space.  Vertical  hepatic  dulness  in  a  line  with  right  nipple  was  Hi 
in.,  in  mesial  line  9f  in.,  and  in  a  line  with  left  nipple  9^  in.  Dis- 
tinct fluctuation  could  be  felt  in  epigastrium  over  a  space  measuring 
4^  in.  transversely  and  2^  in.  vertically ;  but  there  was  now  no 
hydatid  fremitus.  N"o  oedema  of  legs.  Patient  was  sallow  ;  her  urine 
contained  no  bile-pigment,  but  was  still  loaded  with  pus.  She  still 
suffered  from  attacks  of  pain  in  region  of  left  kidney,  which  were 
always  relieved  by  a  sensation  of  bursting  and  a  copious  discharge 
of  pus  in  urine.  On  admission,  there  was  a  considerable  amount  of 
pain  and  tenderness  in  region  of  tumour  near  umbilicus.  This  pain 
recurred  from  time  to  time,  but  was  always  relieved  by  leeches,  poul- 
tices, and  morphia.  Patient  also  had  an  attack  of  pain  and  stiffness 
in  left  groin  and  knee,  accompanied  by  enlargement  of  lymphatic 
glands  in  groin,  and  slight  oedema  in  upper  part  of  thigh.  On  Jan. 
26,  1864,  it  was  noted  that  she  was  free  from  pain,  but  that  she  had 
lost  flesh  and  strength.  On  Feb.  9  she  was  discharged  for  unruly 
conduct. 

The  patient  was  confined  to  bed  after  leaving  hospital,  and  died 
rather  suddenly  and  unexpectedly  at  end  of  ten  days.  An  hour  before 
death  she  seemed  tolerably  well,  and  the  probability  is  that  the  fatal 
event  was  due  to  the  bursting  of  a  hydatid  ej^st. 

Case  XLIII. — Hydatid  Tumours  of  Liver  and  Peritoneum,  compressing 
Ureters,  and  causing  Degeneration  of  Kidneys. 

Mary  Ann  W ,  aged  45,  adm.  into  Middlesex  Hosp.  Dec.  15, 

1864,  under  cai^e  of  Dr.  H.  Thompson,  and  died  Jan,  15,  1865,  For 
a  year  before  death  she  had  suffered  from  headache  and  impairment  of 
mental  faculties,  and  seven  weeks  before  death  she  had  a  fit  of  uncon- 
sciousness, followed  by  right  hemiplegia,  involuntary  evacuations,  and 
bed-sores.     There  were  no  symptoms  referable  to  liver. 

The  arteries  at  base  of  brain  were  atheromatous,  and  there  was  an 
apoplectic  cyst,  with  a  patch  of  white  softening  in  left  corpus  striatum. 
Liver,  spleen,  and  diaphragm  were  adherent  by  fibrous  bands.  In  the 
adhesions  between  spleen  and  liver  was  a  cyst  the  size  of  a  walnut, 
filled  with  soft  putty-like  matter,  and  lined  by  portions  of  a  gelatinous 
hydatid  membrane.  In  right  lobe  of  liver  was  another  cyst,  the  size 
of  a  small    cocoanut,   partly  embedded  in  its  substance  and  partly 


128  ENLARGEMENTS    OF   THE    LIVEE.  lect.  in. 

projecting  from  its  upper  surface,  where  it  was  firmly  adherent  to 
diaphragm.  Its  outer  wall  was  partly  calcified,  and  its  interior  was 
full  of  fragments  of  secondary  gelatinous  cysts  and  soft  putty-like 
matter.  Secreting  tissue  of  liver  healthy.  In  folds  of  mesentery  of 
small  intestine  were  three  partly  calcified  cysts,  varying  in  size  from 
a  hazel-nut  to  a  walnut,  and  containing  putty-like  matter  and  second- 
ary cysts.  Greater  part  of  pelvis  was  occupied  by  another  large 
cyst,  situated  behind  and  above  uterus,  which  was  forced  down  so  as 
to  appear  at  vulva.  This  cyst  contained  a  clear  fluid  and  innumerable 
small  cysts,  varying  in  size  from  a  pea  to  a  walnut,  all  of  them  gelati- 
nous and  filled  with  a  clear  fluid  Another  cyst,  not  so  large,  in  right 
side  of  pelvis.  Ureters  were  compressed  by  these  cysts,  and  pelves  of 
kidneys  somewhat  dilated.  Kidneys  small  and  granular,  and  cortices 
w^asted  and  hardly  distinguishable  from  cones.  All  of  cysts  in  ab- 
domen contained  booklets  of  echinococci. 

In  the  following  case  secondary  hydatid  cysts  were  formed 
in  the  omentum  and  peritoneal  cavity. 

Case  XLIV. — Hijdafid  Cysts  of  Liver  and  Peritoneum — Ascites  and 
Anasarca  of  Loiver  Extremities — Albuminuria — Death. 

Catherine  C ,  a  hawker,  aged  45,  was  a  patient  in  Middlesex 

Hospital  from  Jan.  10,  1865,  until  her  death  on  June  21.  With  excep- 
tion of  an  attack  of  rheumatism,  she  had  enjoyed  good  health  until 
about  a  month  before  admission,  when  she  had  been  seized  with  violent 
pain  in  abdomen  and  loins,  and  at  same  time  her  legs  and  abdomen  had 
begun  to  swell.  While  in  hospital,  she  had  ascites  and  great  anasarca 
of  lower  extremities  ;  urine  contained  albumen.  She  was  treated  with 
diuretics  and  purgatives,  and  her  legs  were  punctured. 

On  examination  of  body,  legs  were  very  cedematous,  and  abdomen 
was  greatly  distended.  Both  lungs  very  cedematous,  and  right  lung 
firmly  adherent  and  carnified  at  its  base. 

Peritoneal  cavity  contained  upwards  of  a  gallon  of  clear  serum, 
floating  about  in  which  were  six  nearly  transparent  hydatid  cysts,  with 
tremulous  gelatinous  walls,  the  largest  about  size  of  a  hen's  e^^,  and 
smallest  about  that  of  a  walnut.  The  fluid  in  the  floating  cysts  had  a 
specific  gravity  of  1010,  and  contained  no  albumen  ;  that  in  peritoneal 
cavity  had  a  specific  gravity  of  1020,  and  was  highly  albuminous. 
Left  lobe  of  liver  partly  atrophied,  and  between  it  and  spleen,  and 
firmly  adherent  to  both  and  to  stomach  was  a  hydatid  cyst  the  size  of 
a  foetal  head,  containing  a  little  clear  fluid  and  innumerable  smaller 
cysts  of  various  sizes  pressed  together.  In  great  omentum  were  three 
or  four  similar  cysts  the  size  of  chestnuts,  and  attached  to  right  kidney 
was  another  cyst  as  big  as  an  orange.  Echinococci  were  found  in  the 
larger  cysts.     Both  kidneys  much  enlarged  and  fatty. 


LECT.  III.  HYDATID    TUMOUE.  1 29 

Case  XLY.  shows  how  closely  hydatid  of  the  liver  may  simu- 
late cancer. 


Case  XLV. — Hydatid  Tumour  of  Liver  simulating  Cancer — Discharge 
of  Hydatids  per  anum,  and  temporary  recovery. 

On  Nov.  1,  1871,  I  saw,  in  consultation  with  Dr.  Mackintosh,  of 
Brompton  Road,  Mr.  C ,  aged  33,  jobmaster,  but  formerly  a  pub- 
lican. His  illness  was  believed  to  have  commenced  only  three  or  four 
months  before  with  an  attack  of  pleurisy  on  right  side  attended  by 
effusion.  Since  then  had  lost  flesh,  and,  two  weeks  before  I  saw  him, 
abdomen  had  begun  to  swell.  Never  had  syphilis  ;  had  not  been  in- 
temperate, and  no  history  of  cancer  in  family.  Over  lower  four-fifths 
of  right  chest  there  was  dulness  continuous  with  that  of  liver,  and 
absence  of  breath-sound  and  of  vocal  thrill.  Heart  displaced  to  left,  but 
no  bulging  of  right  side,  and  measurement  of  two  sides  equal.  Mode- 
rate ascites.  Lower  margin  of  right  lobe  of  liver,  three  or  four  inches 
below  ribs,  distinctly  nodulated  and  tender.  Occasional  vomiting,  but 
no  jaundice. 

Four  days  after  this  feet  began  to  swell,  and  oedema  rapidly  in- 
creased ;  and  on  Nov.  8,  when  I  saw  patient  a  second  time,  temp.  101°, 
and  pericardial  friction  over  heart. 

I  did  not  see  patient  again,  for,  soon  after  my  second  visit,  he  was 
removed  to  Brighton.  Here,  I  am  informed  by  Dr,  Mackintosh,  he 
passed  a  large  quantity  of  hydatid  cysts  per  anum,  the  dropsy  disap- 
peared, and  he  got  so  much  better  that  he  was  able  to  return  to  his 
employment  in  London.  He  died,  however,  about  a  year  afterwards, 
while  under  the  care  of  another  medical  man. 

Case  XLVI. — Hydatid  Tumour  of  Liver — Secondary  Hydatid  Tumours 
in  Spinal  Canal — Paraplegia. 

The  preparation  of  this  case  is  in  the  museum  of  Middlesex  Hos- 
pital (v.  15),  and  the  following  particulars  are  extracted  from  the 
Catalogue  : — ■ 

'  Vertebrse  with  spinal  cord  from  dorsal  region.  The  canal  and 
dura-mater  laid  open.  The  pleura  is  separated  from  the  ribs,  and  the 
sides  of  the  bodies  of  the  vertebrse  by  two  hydatid  cysts,  one  on  each 
side.  The  hydatids  have  been  opened  in  sawing  through  the  laminae 
of  the  vertebrse  ;  but  their  walls  remain,  and  the  spinal  cord  is  at  this 
place  considerably  smaller  than  elsewhere. 

'  The  patient  was  a  woman  aged  40,  who  had  been  admitted  into 
the  hospital  with  paraplegia  and  retention  of  urine.  She  died  with  a 
large  slough  on  the  sacrum,  and  the  bladder  was  found  to  be  inflamed. 
There  was  also  a  large  hydatid  cyst  in  the  liver.' 

In  the  following  case  a  process  of  spontaneous  cure  appears 

K 


I  30  ENLARGEMENTS    OF    THE    LIVER.  lect.  hi. 

to  have  commenced  in  the  tumour,  and  the  observation  is  in- 
teresting in  connection  with  the  manner  in  which  a  c;ire  is 
probably  effected  in  a  hydatid  tumour,  when  the  fluid  contents 
are  drawn  ofi"  by  means  of  a  small  trocar  and  cannula  (see  pages 
73  and  83). 

Case  XLVII. — Large  Hydatid  Tumour  of  Liver,  full  of  secondary 
Cysts,  hut  containing  no  Fluid. 

This  liver  was  taken  from  body  of  a  man,  aged  36,  who  was  ad- 
mitted into  the  Fever  Hospital  on  Dec.  2,  1866,  with  hsemorrhagic 
small-pox,  of  which  he  died  on  Dec.  5.  He  was  too  ill  to  give  any 
particulars  of  his  previous  history. 

After  death,  a  hydatid  tumour,  the  size  of  a  child's  head,  was  found 
in  posterior  part  of  right  lobe  of  liver.  The  chief  points  of  interest 
in  the  case  were  that  this  cyst  was  tightly  packed  with  secondary  cysts, 
and  that  it  contained  no  fluid.  The  secondary  cysts  were  collapsed  ; 
but  still  they  exhibited  their  natural  gelatinous  appearance.  They 
were  not  at  all  opaque  or  mixed  up  with  any  putty-like  material.  The 
outer  cyst,  however,  at  several  places  presented  an  atheromatous  calci- 
fied appearance. 

Case  XLVIH. — Large  Hydatid  of  Liver  undergoing  ^spontaneous  cure  ' 
froin  calcification  of  cyst,  and  discovered  after  forty -five  years. 

On  Feb.  10,  1873,  I  was  requested  by  Dr.  W.  Steer  Riding  to  see 

Mr.  W ,  aged  56,  on  account  of  a  remarkable  tumour  connected 

with  the  liver.  Liver  did  not  ascend  too  high  in  front  or  at  back  ;  but 
lower  margin  of  right  lobe  descended  to  two  inches  below  umbilicus, 
and  the  portion  below  ribs  felt  as  hard  as  bone,  and  was  smooth  and 
painless.  Patient  had  no  symptoms  referable  to  tumour,  and  had  led 
an  active  life,  until  a  trifling  ailment  of  lungs  led  to  discovery  by  Dr. 
Riding  of  tumour,  as  to  existence  of  which  patient  himself  was  igno- 
rant. He  remembered,  however,  that  when  a  child,  at  least  45  years 
before,  he  had  been  brought  a  long  distance  from  the  country  to 
London  to  see  Sir  Astley  Cooper  and  another  surgeon  ;  that  his  liver 
had  then  been  said  to  be  four  times  its  proper  size,  and  had  been 
thought  to  contain  fluid,  and  that  there  had  been  a  question  of  per- 
forming an  operation.  It  had  been  decided  not  to  interfere,  and  the 
tumour  bad  gradually  got  smaller  as  he  had  grown  older. 


CONGESTION.  I3I 


LECTUEE    IV. 
ENLARGEMENTS   OF  THE  LIVER. 

CONGESTION — INTERSTITIAL    HEPATITIS INFLAMMATION    OF 

BILE-DUCTS — OBSTRUCTION   OP   COMMON    DUCT. 

Gentlemen, — In  tlie  previous  lectures  I  have  called  your  at- 
tention to  the  distinguishing  characters  of  the  four  enlarge- 
ments of  the  liver  which  are  for  the  most  part  unattended  by 
pain.  Those  in  which  pain  is  a  prominent  symptom  remain  to 
be  considered.  Seven  diseases  are  included  under  this  head ; 
viz.  1.  congestion  of  the  liver  ;  2.  interstitial  hepatitis  ;  3.  in- 
flammation of  the  bile-ducts;  4.  obstruction  of  the  common 
duct  and  retention  of  bile ;  5.  pysemic  abscesses ;  6.  tropical 
abscess ;  7.  cancer.  Speaking  generally,  it  may  be  said  that 
jaundice,  which  is  a  rare  symptom  in  painless  enlargements  of 
the  liver,  is  present  to  a  greater  or  less  extent  in  the  class  of 
enlargements  now  to  be  noticed ;  tropical  abscess  is  the  one  in 
which  it  is  oftenest  absent.  Ascites  is  also  a  common  symptom. 
First  among  the  enlargements  of  the  liver  attended  by  pain 
comes — 

V.    CONGESTION    OP    THE    LIVER. 

In  the  first  place,  it  is  necessary  to  bear  in  mind  in  reference 
to  the  pathology  and  treatment  of  this  condition,  that  the 
quantity  of  blood  in  the  liver  varies  greatly  at  different  times 
consistently  with  health,  and  that  even  these  healthy  variations 
may  influence  to  some  extent  the  size  of  the  organ.  For 
instance,  the  amount  of  blood  in  the  liver  and  its  size  are 
greatly  influenced  by  diet,  both  being  temporarily  increased 
after  a  meal,  and  particularly  when  the  food  has  been  too  large 
in  quantity,  or  has  contained  an  excess  of  fatty,  saccharine,  or 
alcoholic  ingredients.  By  morbid  congestion  of  the  liver,  we 
mean  something  more  than  this.  The  phrase  "^  congestion  of 
the  liver  '  is  too  often  used  very  vaguely,  and  applied  to  cases  of 

K  2 


132  ENLARGEMENTS    OF    THE    LIVEE.  lect.  rv. 

indio-estion  where  there  is  probably  little  amiss  with  the  liver. 
True  congestion  of  the  liver  is  distinguished  bj  the  following 
characters  : — 

1.  There  is  enlargement  of  the  liver  which  is  uniform  in 
character — not  greater  in  one  direction  than  in  another — and 
which  is  rarely  very  great.  The  liver  may  project  an  inch  or 
more  below  the  margin  of  the  ribs  in  the  right  mammary  line. 
In  the  venous  engorgement  from  mechanical  obstruction  of  the 
circulation,  the  enlargement  is  usually  greater  than  in  active 
congestion,  where  the  engorgement  commences  in  the  arteries. 
Another  peculiarity  of  this  enlargement  is  that  it  is  rarely  per- 
manent, but  that  after  a  time  it  usually  disappears.  Even  when 
the  cause  of  the  congestion  is  most  permanent,  such  as  me- 
chanical obstruction  of  the  cardiac  circulation  from  valvular 
disease  of  the  heart,  the  enlargement  of  the  liver  gives  place 
after  a  time  to  an  opposite  condition  of  contraction.  The 
pressure  exerted  by  the  constantly  distended  hepatic  veins 
causes  atrophy  of  the  central  portions  of  the  lobules,  and  induces 
a  form  of  granular  liver,  different  from  true  cirrhosis,  where  the 
atrophy  commences  at  the  circumference  of  the  lobules. 

2.  The  surface  of  the  portion  of  liver  projecting  below  the 
ribs  is  smooth. 

3.  The  patient  complains  of  a  feeling  of  tightness  or  painful 
distension  in  the  region  of  the  liver,  and  there  is  more  or  less — 
but  rarely  very  acute — tenderness  on  pressure  below  the  margin 
of  the  right  ribs.  The  pain  and  feeling  of  uneasiness  may,  in 
consequence  of  the  connection  of  the  subclavius  nerve  with  the 
phrenic,  stretch  up  to  the  right  shoulder,  and  they  are  almost 
always  increased  after  meals  or  by  lying  on  the  left  side.  In 
the  latter  case  there  is  usually  a  sense  of  dragging  or  weight 
in  the  hepatic  region.  The  patient  consequently  sleeps  for  the 
most  part  on  his  back,  or  on  his  right  side. 

4.  Jaundice  is  present  in  most  cases  after  two  or  three  days, 
but  is  rarely  intense,  and  it  is  not  often  that  bile  is  altogether 
absent  from  the  motions.  When  there  is  intense  jaundice  with 
absence  of  bile  from  the  stools,  catarrh  of  the  ducts  is  probably 
present,  as  well  as  congestion  of  the  hepatic  tissue. 

5.  There  is  usually  nausea,  with  loss  of  appetite,  headache, 
furred  tongue,  a  bitter  taste  in  the  mouth,  flatulence,  and  other 
symptoms  of  indigestion,  and  not  unfrequently  there  is  vomiting 
or  diarrhoea,  or  both.  The  same  cause  that  produces  congestion 
of  the  liver  may  induce  a  similar  condition  of  the  stomach  and 


i.ECT.  IV.  CONGESTION".  1 33 

intestines;  slight  irritation  then  suffices  to  induce  catarrhal 
inflammation  of  the  mucous  membrane  of  these  parts,  of  which 
vomiting  and  diarrhcea  are  the  prominent  symptoms.  With 
these  derangements  of  digestion  it  is  not  uncommon  to  find 
ana3mia,  general  languor  and  debility,  emaciation,  depression  of 
spirits,  drowsiness,  and  hypochondriasis. 

6.  More  or  less  dyspneea  is  not  uncommon,  even  in  cases 
where  the  primary  disease  is  not  in  the  chest,  and  many 
patients  are  harassed  by  a  frequent  dry  cough.  The  dyspnoea 
may  be  so  great  as  to  raise  the  suspicion  of  serious  mischief  in 
the  heart  or  lungs,  but  it  is  often  entirel}''  removed  by  free 
purgation. 

7.  Signs  of  obstructed  portal  circulation  are  not  uncommon. 
In  acute  cases  there  may  be  tension  in  the  left  hypochondrium, 
and  an  increased  area  of  splenic  dulness ;  while  in  more  pro- 
tracted cases  there  may  be  haemorrhoids  or  ascites. 

8.  The  urine  is  usually  scanty  and  high-coloured,  and  besides 
containing  more  or  less  bile-pigment,  often  deposits  a  copious 
sediment  of  lithates  or  lithic  acid.  Temporary  albuminuria  is 
not  uncommon. 

9.  As  in  other  forms  of  enlargement  of  the  liver,  the  cir- 
cumstances under  which  the  enlargement  appears  constitute  an 
important  aid  to  the  diagnosis  of  the  real  nature  of  the  case. 
Hepatic  congestion  may  be  mechanical,  active,  or  passive,  and 
the  chief  conditions  under  which  it  occurs  are  the  following  : — 

A.  Mechanical. — Among  the  most  common  causes  of  hepatic 
congestion  in  this  country  is  mechanical  obstruction  of  the 
circulation  in  the  chest,  and  particularly  that  consequent  on 
disease  of  the  mitral  or  tricuspid  valves  of  the  heart.  In  many 
cases  of  valvular  disease  of  the  heart,  a  time  arrives  when  the 
chief  symptoms  are  those  of  hepatic  congestion,  and  the  main 
treatment  must  be  directed  to  their  relief. 

B.  Active. — Several  causes  contribute  to  the  development  of 
active  congestion  : — 

a.  Irritating  ingesta,  in  the  form  of  alcohol,  fermented 
liquors,  spices,  or  food  which  errs  in  being  habitually  too  rich 
in  quality  or  in  excessive  quantity  may  cause  congestion  of  the 
liver.  The  temporary  increase  of  blood  in  the  liver  always  present 
after  a  meal  may  become  morbid  in  degree  and  permanent,  if 
the  ingesta  be  habitually  of  an  irritating  character.  Conges- 
tion of  the  liver  is  more  likely  to  result  from  these  causes  in 
weakly  persons  who  lead  indolent  and  sedentary  lives,  than 


1 34  ENLARGEMENTS   OF    THE    LIVER.  lect.  iv. 

in  persons  of  a  robust  constitution  who  take  plenty  of  muscular 
exercise  in  tlie  open  air. 

h.  A  high  temperature  is  usually  reckoned  among  the  causes 
of  congestion  of  the  liver,  but  probably  rarely  leads  to  such  a 
result  except  in  conjunction  with  irritating  ingesta.  It  is  to 
this  combination  of  causes  that  must  be  attributed  the 
frequency  of  active  congestion  of  the  liver  among  Europeans  in 
■warm  climates.     (See  Lect.  XVI.) 

c.  A  sudden  or  protracted  chill  may  induce  congestion  of 
the  liver,  especially  in  warm  climates,  in  persons  who  have 
been  free  livers,  or  after  violent  exercise. 

d.  Malaria  and  Blood-Poisons. — Persons  who  suffer  from 
malarious  fevers,  or  live  in  malarious  districts,  are  very  prone 
to  have  congestion  of  the  liver,  which  may  persist  long  after  the 
febrile  symptoms  have  passed  away.  Officers  and  soldiers  not 
uncommonly  return  from  India  with  enlargement  of  the  liver 
from  this  cause.  But  when  great  and  permanent  enlargement  of 
the  liver  succeeds  to  ague  or  remittent  fever,  it  is  more  probably 
the  result  of  waxy  deposit,  or  of  interstitial  hepatitis,  than  of 
simple  congestion.'  There  a,re  other  blood-poisons,  besides  ma- 
laria, which  may  induce  congestion  of  the  liver,  such  as  the  yellow 
fever  of  the  tropics,  and  the  relapsing  fever  of  our  own  country. 

e.  Active  congestion  of  the  liver  may  have  a  traumatic 
origin,  and  result  from  contusions,  wounds,  &c. 

C.  Passive. — Passive  congestion  of  the  liver  may  be  due 
to:— 

a.  Suppression  of  habitual  discharges,  as  of  the  catamenia, 
or  of  the  bleeding  from  piles.  I  have  repeatedly  known  conges- 
tion of  the  liver,  and  even  cirrhosis,  follow  a  successful  operation 
for  piles. 

h.  Habitual  constipation. 

c.  Torpor  of  the  portal  vascular  system  from  paralysis  of  the 
sympathetic  nerves  or  from  any  other  cause. 

d.  Insufficient  muscular  exercise. 

Treatment. — In  the  treatment  of  hepatic  congestion,  you 
must  be  guided  by  the  following  rules : — 

1.  In  all  cases  it  is  well  to  commence  by  removing,  if  pos- 
sible, the  cause.  The  measures  to  be  adopted  for  this  object 
will  be  apparent  from  what  has  already  been  stated. 

2.  In  most  cases  of  any  severity  advantage  will  be  derived 

'  Sec  paj^e  36  and  Case  X.,  and  also  Morehead,  Res.  ou  Dia.  in  India,  1860,  p. 
42S  ;  and  Sir  Ii.iiiald  Martin,  in  Lancet,  1865,  ii.  p.  Gir>. 


lECT.  IV.  CONGESTION.  1 35 

from  the  employment  of  local  depletion  in  the  form  of  leeches 
or  of  cupping  to  the  region  of  the  liver,  or,  what  is  still  better, 
the  application  of  a  few  leeches  around  the  anus.  If  depletion 
be  deemed  inexpedient,  sinapisms  may  be  applied  over  the  liver. 
After  the  leeches  or  the  sinapisms,  their  place  ought  to  be 
supplied  by  linseed  or  bran  poultices.  Tepid  baths  are  sometimes 
useful. 

3.  The  diet  should  be  of  the  least  irritating  character. 
Only  small  quantities  of  milk,  beef- tea,  or  farinaceous  articles 
ought  to  be  taken  at  a  time.  Alcohol,  wine,  fermented  liquors, 
spices,  fat,  and  all  rich  or  indigestible  articles  ought  to  be 
rigidly  interdicted.  In  modern  practice  much  mischief  is  often 
done  by  compelling  patients  with  heart-disease  and  congestion 
of  the  liver  to  swallow  large  quantities  of  brandy. 

4.  Purgatives  are  in  most  cases  of  great  utility,  unless 
there  be  spontaneous  diarrhoea,  which  ought  not  to  be  too 
speedily  or  completely  checked.  Purgatives  in  fact  are  the  best 
means  of  checking  the  frequent,  but  fruitless,  calls  to  stool  from 
which  the  patient  often  suffers.  The  best  purgatives  are  those 
salines  which  increase  the  watery  exhalation  from  the  mucous 
membrane  of  the  bowels,  such  as  the  sulphates  of  magnesia, 
potash,  and  soda,  the  tartrate  of  potash  and  soda,  seidlitz 
powders,  Carlsbad  salt,  and  Priedrichshall  or  Piillna  water. 
These  salts  ought  to  be  dissolved  in  warm  water  and  taken  in 
the  morning  on  an  empty  stomach.  Their  action  is  often 
materially  assisted  by  an  occasional  dose  of  calomel,  blue-pill, 
or  podophyllin,  which  bring  away  copious  bilious  motions.^ 

5.  When  the  congestion  is  traceable  to  irritating  ingesta, 
an  emetic  in  the  early  stage  sometimes  appears  to  do  good,  by 
clearing  out  the  stomach  and  duodenum.  The  pressure  also  to 
which  the  liver  is  subjected  during  the  act  of  vomiting  may 
squeeze  out  of  it  some  of  the  superfluous  blood. 

6.  During  the  persistence  of  the  symptoms  of  congestion — 
enlargement  and  tenderness  of  the  liver  with  jaundice — and 
especially  in  those  cases  where  there  is  much  gastric  derange- 
ment, alkalies  and  their  salts  with  the  vegetable  acids  ought  to 
be  prescribed.     They  may  be  taken  two  or  three  times  a  day 

'  The  increased  biliary  excretion  after  the  calomel  in  these  cases  is  not  due  to  an 
increased  secretion  of  bile  by  the  liver,  but  probably  to  the  mercury  acting  upon  the 
upper  part  of  the  small  intestine,  so  that  the  bile  is  propelled  onwards,  instead  of 
being  reabsorbed  (see  Lect.  IX).  If  calomel  acted  by  stimulating  the  liver  to  increased 
secretion,  it  would  be  injurious  in  cases  of  hepatic  congestion. 


1 36  ENLARGEMENTS    OF   THE    LIVER.  xect.  it. 

shortly  before  meals.  The  alkaline  mineral  waters,  such  as 
those  of  Vals,  Vichy,  and  Ems,  or  the  artificial  effervescing 
Vichy  salt,  may  often  be  advantageously  substituted  for  the 
alkaline  preparations  of  the  Pharmacopoeia. 

7.  The  chloride  of  ammonium  has  been  found  to  be  of 
great  utility  in  hepatic  congestion  in  this  country  as  well  as  in 
India.'  In  doses  of  twenty  grains  two  or  three  times  daily,  it 
induces  free  diaphoresis,  increases  the  flow  of  urine,  diminishes 
portal  congestion,  and  relieves  hepatic  pain.  It  is  believed  also 
to  stimulate  the  absorbents,  especially  those  in  the  liver,  and 
thus  to  effect  the  absorption  of  hepa,tic  abscess.  It  may  be 
given  in  combination  with  either  alkalies  or  acids. 

8.  Ipecacuanha  has  been  recommended  by  Dr.  C.  Maclean  ^ 
as  one  of  the  best  and  safest  remedies  in  the  acute  hypersemia 
of  the  liver,  which  in  tropical  climates  is  so  often  the  precursor 
of  suppurative  inflammation.  He  believes  it  to  be  a  blood- 
depurant ;  it  increases  the  secretion  of  the  liver  and  skin,  and  so 
there  can  be  no  doubt  as  to  its  beneficial  action  in  the  cases 
referred  to.  It  is  a  notable  fact  that  since  ipecacuanha  has 
come  into  general  use  in  the  treatment  of  dysentery  in  India, 
abscess  of  the  liver  has  become  much  less  frequent.  As  in 
dysentery,  it  must  be  given  in  large  doses  (20  to  30  grains) 
every  six  or  twelve  hours  according  to  the  severity  of  the  case. 
Quarter  of  a  grain  of  tartar  emetic  and  15  grains  of  nitrate  of 
potash,  given  every  half-hour  until  the  pain  is  relieved,  is  said  to 
act  in  a  similar  manner. 

9.  When  the  more  urgent  symptoms  have  passed  off,  and 
the  patient  suffers  chiefly  from  debilit}',  anaemia,  and  dyspepsia, 
with  a  slight  increase  of  the  hepatic  dulness,  with  or  without 
hypochondriasis,  the  treatment  may  be  modified.  The  mineral 
acids  and  vegetable  tonics  are  now  often  useful,  such  as  the 
mineral  acids  with  taraxacum,  nux  vomica,  or  gentian.  Quinine 
and  iron  are  particularly  indicated  in  patients  who  have 
suffered  from  malarious  fevers  ;  but  ought  to  be  given  with 
great  caution  to  persons  of  gouty  habit,  or  who  have  been  free 
livers.  The  diet  ought  also  to  be  more  generous,  although  care 
must  be  taken  to  exclude  from  it  every  source  of  irritation. 
Fermented  liquors  ought  still  to  be  interdicted,  and  if  wine  be 

•  Although  this  drup;  had  been  long  used  in  various  hepatic  disorders,  its  value  in 
the  trfatment  of  hepatic  congestion  was  first  made  known  in  1869  by  Dr.  William 
Stewart,  of  II. M.  Army. 

*  Eeynolds's  System  of  Med.  iii.  337. 


LECT.  IV.  CONGESTION.  1 37 

allowed  at  all,  it  should  be  given  in  small  quantities,  and  diluted. 
Hock,  claret,  and  dry  sherry  are  the  best.  Kegular  exercise  in 
the  open  air  ought  to  be  enjoined;  if  there  be  much  debility, 
the  advantages  of  exercise  without  fatigue  may  be  derived  from 
riding  on  horseback.  The  bowels  will  still  require  attention, 
and  great  benefit  will  often  be  obtained  from  the  use  of  mineral 
waters  which  combine  chal3^beate  with  purgative  properties, 
such  as  the  springs  of  Harrogate,  Cheltenham,  Leamington, 
Homburg,  and  Kissingen. 

10.  It  is  in  the  chronic  condition  last  referred  to  that  advan- 
tage is  sometimes  derived  from  the  use  of  the  nitro-muriatic  acid 
bath,  as  recommended  by  Sir  Ranald  Martin.^  The  bath  should 
consist  of  two  ounces  of  strong  hydrochloric  and  one  ounce  of 
strong  nitric  acid  to  two  gallons  of  water,  at  a  temperature  of 
96°  or  98°.  Both  feet  are  to  be  placed  in  the  bath,  while  the 
inside  of  the  legs  and  thighs,  the  right  side  over  the  liver,  and 
the  inside  of  both  arms,  are  sponged  alterjiately,  or  the  abdomen 
may  be  swathed  in  flannel  soaked  in  the  fluid.  The  process  is 
to  be  continued  for  half  an  hour  night  and  morning.^  In 
obstinate  cases  advantage  is  sometimes  derived  from  the  hydro- 
pathic belt,  or  from  inunction  with  the  ointment  of  biniodide  of 
mercury. 

As  an  example  of  congestion  of  the  liver  resulting  from 
mechanical  obstruction  of  the  circulation  in  the  chest,  I  may 
call  your  attention  to  the  following  case  : — 

Case  XLIX. — Mitral  Stenosis — Dropsy  and  Congestion  of  Liver — 

Death. 

Emma  F ,  aged  13,  adm.  into  Middlesex  Hosp.  Oct.  24,  1865, 

suffering  from  mach  cough,  great  dyspnoea,  and  considerable  anasarca 
of  lower  extremities.  Cardiac  dulness  had  double  its  normal  area,  and 
a  prolonged  bellows-murmur  was  audible  over  left  apex.  There  were 
all  the  signs  of  general  bronchitis  ;  and,  in  addition,  conjunctiva  and 
general  surface  had  a  slightly  jaundiced  tint ;  hepatic  dulness  was 
much  increased,  measuring  in  right  mammary  line  more  than  5 
in.    and   extending  down  nearly  to  umbilicus.     Splenic  dulness  also 

1  See  Lancet,  Dec.  9,  1865,  p.  641. 

*  The  bath,  as  above  prepared,  may  be  kept  in  use  for  a  few  days,  1  drachm  of 
hydrochloric  and  half  a  drachm  of  nitric  acid,  with  a  pint  of  water,  being  added  daily 
to  make  up  for  waste.  About  a  fourth  of  the  fluid  is  to  be  well  heated  in  an  earthen 
pipkin,  so  as  to  bring  up  the  temperatiire  of  the  whole  to  96°  or  98°.  Glazed  earthen 
or  wooden  vessels  should  be  used,  and  the  sponges  and  towels  should  be  kept  in  cold 
water,  lest  the  acid  corrode  them. 


138  ENLARGEMENTS    OF   THE    LIVER.  lect.  iv. 

increased.  Considerable  tenderness  below  right  ribs.  Tongue  furred. 
Much,  nausea  and  occasional  vomiting,  and  bowels  relaxed  about  four 
or  five  times  a  day  ;  motions  pale,  though  coloured  with  bile.  Urine 
contained  a  small  amount  of  bile-pigment,  but  no  albumen.  Five  or 
six  years  before,  this  patient  had  an  attack  of  scarlet  fever,  followed  by 
articular  rheumatism  and  dropsy.  Ever  since,  she  had  suffered  fi-om 
dyspnoea  and  palpitations,  increased  by  any  exertion.  About  ten  days 
before  admission  she  began  to  complain  of  cough,  headache,  and  vomit- 
ing, and  swelling  appeared  in  ankles,  which  gradually  extended 
upwards. 

The  treatment  consisted  in  administration  of  purgatives  and 
diuretics,  and  particularly  the  bitartrate  of  potash  and  tincture  of  digi- 
talis, while  leeches  and  mustard  and  linseed  poultices  were  applied  over 
right  hypochondrium.  At  first  there  was  a  manifest  improvement  in 
all  the  symptoms  ;  but  about  a  fortnight  after  admission  the  indications 
of  obstructed  cardiac  circulation  became  aggravated  ;  dyspnoea  and 
dropsy  increased,  lips  and  face  were  livid  :  jaundice  was  more  marked, 
vomiting  more  urgent,  and  motions  contained  less  bile.  Pulse  was 
very  rapid,  and  on  Nov.  10  scarcely  perceptible.  At  11  p.m.  of  this 
day  the  girl  died. 

On  examination  of  body,  heart  was  much  enlarged,  weighing  13 
oz.  ;  mitral  valve  much  thickened  and  its  margins  adherent,  so  that 
orifice  was  contracted,  and  its  circumference  measured  only  fifteen 
lines.  Both  lungs  much  congested,  and  presented  the  ordinary  anato- 
mical characters  of  bronchitis  ;  but  they  were  nowhere  consolidated. 
Peritoneum  contained  about  a  pint  of  clear  serum.  Liver  very  large 
for  patient's  age,  weighing  nearly  4  lbs  ;  outer  surface  smooth  ; 
and,  on  section,  roots  of  hepatic  vein  gorged  with  dark  blood,  con- 
trasting strongly  with  intermediate  pale-yellow  hepatic  tissue.  On 
microscopic  examination,  quantity  of  oil  in  secreting  cells  did  not  seem 
increased.  Spleen  weighed  6^  oz.,  and  was  firm  and  dark  on  sec- 
tion. Pyramids  of  kidneys  much  congested,  but  renal  tissue  in  other 
respects  healthy.  Mucous  membrane  of  pyloric  half  of  stomach  pi-e- 
sented  ordinary  characters  of  catarrhal  inflammation. 

As  an  illustration  of  congestion  of  the  liver  arising  from 
other  causes  I  may  narrate  to  you  the  following  case  : — 

Case  L. — Indigestion  from  Hohitual  Surfeit- — Residence  in  Tropics — 
Exposure  to  Chill — Congestion  of  Ldver. 

Mr.  C ,  aged  30,  a  gentleman  much  addicted  to  the  pleasures 

of  the  table,  coTisulted  me  in  June  1867,  on  his  return  from  India. 
He  had  for  several  years  suffered  from  constipation,  flatulence,  and  a 
feeling  of  weight  and  oppression  in  region  of  liver.  About  six  weeks 
before  I  saw  him,  he  was  attacked  with  pain  in  region  of  liver  followed 
by  vomiting  and  jaundice,  after  sleeping  on  a  verandah  in  the  night 


LECT.  IV.  INTERSTITIAL    HEPATITIS.  139 

air  in  India.  He  had  leeches  applied  over  liver,  and  was  ordered  home 
at  once.  I  found  him  still  moderately  jaundiced  ;  liver  enlarged,  mea- 
suring 6  in.  in  right  mammary  line,  and  slightly  tender ;  no  vomit- 
ing, but  bowels  constipated  ;  a  bitter  taste  in  mouth,  and  nausea. 
Motions  light  but  contained  bile.  Urine  scanty,  dark,  contained  bile- 
pigment,  deposited  much  lithates,  and  became  very  dark  on  addition 
of  nitric  acid  after  heating.  He  was  treated  with  saline  purgatives 
and  occasional  pills  of  the  comp.  colocynth  mass  (gr.  vi),  podophyllin 
(gr.  ^),  and  extract  of  henbane  (gr.  ii)  ;  an  effervescing  mixture  of 
citrate  of  potash  was  ordered  to  be  taken  three  times  a  day  ;  a  warm 
bath  three  times  a  week  ;  moderate  exercise  ;  and  a  simple  diet,  from 
which  alcohol  in  every  form  was  excluded.  At  the  end  of  ten  days 
patient  was  much  improved,  jaundice  had  almost  gone,  and  hepatic 
dulness  diminished.  A  mixture  with  nitric  acid  and  compound  infu- 
sion of  gentian  was  now  substituted,  and  in  two  or  three  weeks  more 
patient  had  regained  his  usual  health. 

VI.    ENLARGEMENT    OP    LIVER    PROM    INTERSTITIAL    HEPATITIS. 

This  form  of  enlargement  of  the  liver  is  a  common  sequel  of 
chronic  hvpersemia.     Its  clinical  characters  are  these  : — 

1.  The  enlargement  is  uniform  in  every  direction,  and  may 
be  much  greater  than  in  simple  congestion.  The  liver  may 
reach  up  to  the  nipple  and  down  to  the  navel,  or  even  lower,  but 
its  lower  margin  is  often  obscured  by  tympanites  or  ascites. 

2.  Its  surface  is  smooth,  or  slightly  uneven,  dense  and  re- 
sisting, and  more  or  less  tender.  Occasionally  there  is  acute 
tenderness  from  intercurrent  attacks  of  peri-hepatitis. 

3.  The  symptoms  in  the  first  instance  are  the  same  as  those 
of  active  hypersenriia,  which  I  have  already  described  to  you,  so 
that  sometimes  it  may  be  difficult  to  say  whether  there  is  con- 
gestion only,  or  congestion  plus  interstitial  hepatitis. 

4.  But  when  the  disease  is  more  pronounced,  its  prominent 
features  are  sallowness  or  slight  jaundice,  venous  stigmata  on 
the  cheeks,  nausea  and  retching,  especially  on  first  rising  in  the 
morning,  loathing  of  solid  food,  particularly  in  the  early  part 
of  the  day,  diarrhoea  alternating  with  constipation,  hsemorrhoids, 
scanty  dark  urine  loaded  with  lithates,  and  in  some  cases  tem- 
porary albuminuria,  depression  of  spirits,  sensations  of  sinking 
and  a  craving  for  stimulants.  Occasionally  there  is  slight 
pyrexia. 

5.  In  a  still  more  advanced  stage  there  will  be  the  various 
symptoms  of  portal  obstruction,  which  I  shall  have  to  describe 
to  you  in  detail  when  we  come  in  a  future  lecture  to  consider 


I40  ENLARGEMENTS    OF    THE    LIVER.  lect.  it. 

cirrhosis  under  the  head  of  contractions  of  the  liver.  The  en- 
largement in  fact  which  I  have  now  described  is  the  disease 
known  as  cirrhosis,  although  when  the  symptoms  of  this  disease 
are  well  pronounced  the  liver  is  more  commonly  contracted. 
In  opposition  to  the  opinion  of  the  late  Dr.  Todd,'  several 
observers,  such  as  Saunders,  Bright,^  Budd,  Frerichs^  have  ex- 
pressed the  opinion  that  in  cirrhosis  the  contraction  of  the 
liver  is  occasionally  preceded  by  a  stage  of  enlargement,  but  as 
far  as  can  be  judged  from  medical  writings  such  an  enlargement 
is  believed  to  be  excej^tional.  Gee  has  recorded  two  cases  of 
*  cirrhotic  enlargement  of  the  liver,'  in  which  the  organ  weighed 
100^  and  104  ounces  respectively.'*  Habershon  has  met  with 
an  inflammatory  induration  of  the  liver,  in  which  the  organ 
becomes  greatly  enlarged  f  and  Duckworth  has  described  a 
'hypertrophic  cirrhosis.'^  From  my  own  experience  I  have 
been  led  to  believe  that  in  a  considerable  proportion  of 
cases  of  cirrhosis,  the  liver  is  still  much  enlarged  (very  often 
from  the  presence  in  the  organ  of  a  large  quantity  of  fat) 
after  ascites  and  other  symptoms  of  portal  obstruction  have  set 
in,  and  that  patients  often  die  in  this  condition  with  jaundice, 
hsemorrhages,  and  symptoms  of  blood-poisoning  (the  prognosis 
being  no  better  than  if  the  liver  were  contracted).  In  this 
opinion  I  am  confirmed  by  the  independent  observations  of 
Professor  Leudet,  of  Eouen,^  who  observes  :  '  On  est  arrive  par 
I'anatomie  pathologique  a  reconnaitre  que  I'augmentation  du 
volume  de  la  glande  n'etait  pas  toujours  I'indice  d'une  lesion 
recente  du  foie,  d'un  processus  aigu  encore  curable.'  This  is 
the  reason  why  I  have  brought  the  disease  under  j^our  notice  on 
the  present  occasion,  but  I  shall  have  occasion  to  return  to  it  in  a 
future  lecture.  It  is  a  matter  for  investigation,  whether,  if  the 
patient  lived  long  enough,  the  enlargement  in  all  these  cases 
would  be  followed  by  marked  cirrhotic  contraction.  M.  Ollivier, 
in  fact,  is  of  opinion  that  cirrhotic  enlargement  is  a  distinct 
affection  from  cirrhotic  contraction.^  There  can  be  no  doubt, 
however,  that  it  occurs  under  the  same  conditions  and  gives  rise 
to  the  same  symptoms.     It  seems  probable,  therefore,  that  the 

'  Clin.  Lect.  on  Urinary  Diseases  and  Dropsies,  18.)7,  p.  113. 

^  Uuy's  IIosp.  Rop.,  1st  ser.  vol.  i.  p.  612. 

'  Dis.  of  Liver,  Syd.  Soc.  Transl.  vol.  ii.  pp.  35,  37,  53. 

*  St.  Earth.  Ilosp.  Kep.  1869,  vol.  v.  p.  108. 

*  Lettsoniian  Lectures,  1872,  p.  56. 

«  St.  liarth.  IIosp.  Kep.  vol.  x.  '  Clin.  Med.,  Paris,  1874,  p.  541. 

*  L'Uniou  Med.  Sept.,  1871,  pp.  3G1,  400,  44'J. 


I^CT.  IV.  INTESSTITIAL    HEPATITIS.  I4I 

same  causes  sometimes  lead  to  contraction,  and  sometimes  to 
enlargement  of  the  liver. 

6.  The  causes  of  interstitial  hepatitis  may  be  said  to  be  these  : 

a.  In  a  large  proportion  of  the  cases  presenting  the  clinical 
features  which  I  have  now  described,  you  will  find  that  the 
patient  has  been  addicted  to  a  free  use  of  alcoholic  drinks.  You 
must  beware  of  being  deceived  in  this  matter.  Such  patients 
may  tell  you,  and  even  really  believe,  that  they  lead  regular  and 
temperate  lives,  because  they  never  drink  a  sufficient  quantity 
of  alcohol  at  one  time  to  obscure  their  intellects ;  but  it  is  the 
practice  of  '  nipping  ' — of  taking  frequently  small  quantities  of 
spirits,  or  a  glass  of  sherry,  under  the  mistaken  notion  that 
this  better  fits  them  for  work, — that  keeps  the  liver  in  a  con- 
stant state  of  congestion,  and  most  surely  leads  to  cirrhosis. 
Moreover,  you  must  not  gauge  one  man's  capacity  for  alcohol  by 
that  of  another.  One  person  may  take  with  impunity,  what  in 
another  will  induce  serious  disease. 

h.  The  congestion  of  the  liver  which  results  from  venous 
obstruction  may  also  lead  to  an  interstitial  hepatitis  presenting 
most  of  the  clinical  characters  which  I  have  now  described 
(Case  LY.),  but  distinguished  from  true  cirrhotic  enlargement  by 
the  presence  of  chronic  cardiac  or  pulmonary  disease,  and  of  the 
signs  of  obstructed  systemic  circulation.  In  rare  cases  I  have 
known  the  liver  from  this  cause  not  only  enlarged,  but  nodu- 
lated. 

c.  Interstitial  hepatitis  resulting  in  enlargement  of  the  liver 
may  also  have  a  syphilitic  origin,  although  more  commonly  in 
these  cases  the  liver  seems  to  contract  from  the  first.  These 
cases  will  be  distinguished  by  the  history  of  constitutional 
syphilis,  and  by  the  greater  tendency  to  attacks  of  severe  peri- 
hepatitis causing  much  pain  and  tenderness.  The  liver  also 
has  a  greater  tendency  to  become  uneven  or  nodulated  from  the 
cicatrix -like  depressions  which  form  upon  its  surface,  or  from 
the  projection  of  enlarged  and  softened  gummata.  In  the 
latter  case  the  disease  may  be  mistaken  for  abscess  *  or  hydatid  ; 
and  indeed,  from  what  was  observed  in  Case  LYII.  and  in  a  case 
recorded  by  Dr.  Moxon^  where  a  syphilitic  gumma  in  the  liver 
softened  into  a  puriform  fluid  and  burst  into  a  bile-duct,  it  seems 
not  improbable  that  a  tumour  of  this  sort  may  occasionally 
discharge  itself  by  the  stomach  or  bowels.     In  other  cases  there 

'  Wilks,  British  Med.  Journ.  1876,  i.  239. 
-  Path.  Trans,  vol.  xxiii.  p.  153. 


142  ENLARGEMENTS    OF    THE    LIVER.  i;ect.  iv. 

may  be  a  difficulty  in  distinguishing  the  disease  in  question 
from  waxy  enlargement  with  peri-hepatitis. 

d.  Lastly,  a  chill,  independently  of  intemperate  habits, 
would  appear  to  be  in  rare  instances  sufficient  to  excite  inter- 
stitial hepatitis  ending  in  great  enlargement  of  the  liver.  Dr. 
Wilson  Fox  has  communicated  to  me  the  particulars  of  such 
a  case,  where  there  was  a  persistent  though  slight  elevation  of 
temperature,  and  I  have  observed  one  or  two  similar  instances, 
in  which,  however,  the  diagnosis  was  not,  as  in  Dr.  Fox's  case, 
verified  by  post-mortem  examination.  It  is  probable  that  in 
these  cases  some  constitutional  dyscrasia  predisposes  to  the 
action  of  the  chill.     (See  Appendix,  Case  CLXXVI.) 

The  treatment  of  interstitial  hepatitis  in  its  early  stage  will 
be  the  same  as  that  which  I  have  already  indicated  as  appro- 
priate for  congestion  ;  that  for  the  advanced  stages  will  be 
more  conveniently  discussed  when  I  come  to  speak  of  cirrhotic 
contraction.  Syphilitic  cases  will  of  course  call  for  specific 
remedies,  and  especially  for  mercury  and  iodide  of  potassium. 

The  four  following  cases  are  examples  of  cirrhotic  enlarge- 
ment of  the  liver  resulting  from  alcohol.  The  first  three  are 
illustrations  of  the  good  effects  of  treatment ;  while  Case  LIV. 
illustrates  the  appearances  found  after  death. 

Case  LI. — Cirrhotic  Enlargement  of  Liver  from  Alcohol  {and  Malaria  /) 
— Great  Ascites — Paracentesis — Recovery  under  treatment. 

On  Jan.  6,  1873,  I  saw,  in  consultation  with  Dr.  A.  Simpson,  of 
Highgate,  Mr.  L.,  aged  35,  an  indigo-planter,  just  returned  from  India, 
-where  he  had  been  born,  and  where  he  had  lived  all  his  life.  Had  been 
a  free  liver  and  drunk  much  spirits,  but  excepting  several  attacks  of 
malarious  fever  had  good  health  until  June  1872,  when  he  began  to 
have  considerable  hepatic  pain,  followed  by  ascites  and  swelling  of 
legs.  Girth  at  umbilicus  on  Jan  5,  37^  in. ;  much  fluid  in  peritoneum  ; 
great  a3dema  of  legs.  Liver  large,  projecting  nearly  4  in.  beyond  right 
ribs,  very  hard  and  distinctly  nodulated.  Urine  had  contained  albu- 
men, but  was  now  free  from  it.  Bowels  confined.  Face  sallow,  with 
venous  stigmata. 

On  supposition  tliat  patient  might  be  suffering  from  effects  of 
malarial  cachexia,  iron,  quinine,  and  strychnia  were  prescribed,  with  an 
aperient  dranglit  every  morning  containing  sulphate  of  magnesia  and 
iodide  of  potassium.  Dropsy,  however,  increased.  On  Jan.  13  girth 
of  abdomen  38|  in.  ;  legs  more  swollen  ;  and  penis  and  scrotum  very 
oodematous.  On  Jan.  26  girth  of  sibdomcn  41  in.  and  respiration  em- 
barrassed.   A  mixture  of  digitalis,  bitartrate  of  potash,  and  juniper  was 


LECT.  IV.  INTERSTITIAL    HEPATITIS.  I43 

now  substituted  for  the  quinine  and  iron,  and  the  purgatives  were 
continued.  Abdomen  was  also  fomented  with  a  strong  infusion  of 
digitalis.  On  Feb.  22  the  mixture  was  changed  for  one  of  percbloride 
of  mercury  and  digitalis.  Under  this  treatment  at  first  slight  and 
temporary  improvement,  but  on  March  3  girth  of  abdomen  42^  in. ; 
signs  of  fluid  in  lower  fourth  of  both  pleural  cavities  ;  orthopnoea ; 
urine  only  30  oz.  Ordered  podophyllin  pills  and  a  mixture  of  digitalis, 
squill,  and  juniper.  On  March  5  about  two  gallons  of  fluid  were  drawn 
ofl"  by  paracentesis,  with  immediate  relief.  At  first  ascites  seemed  to 
be  collecting  again,  and  on  March  8  girth  oE  abdomen  38  in.  ;  but  after 
this  swelling  of  abdomen  slowly  receded,  and  on  March  31  girth  only  32 
in. ;  no  fluid  in  pleures.  Liver  still  reached  down  to  umbilicus,  hard  and 
nodulated.  Purgatives  were  continued,  and  a  pill  three  times  a  day 
containing  gr.  ^  of  green  iodide  of  mercury  was  substituted  for  diuretic 
mixture,  and  red  iodide  of  mercury  ointment  was  rubbed  in  over  liver. 
The  iodide  of  mercury  was  continued  for  two  months,  dose  being  gi'adn- 
ally  increased  to  gr.  ^.  Under  this  treatment  he  steadily  improved.  On 
April  29  he  was  able  to  drive  four  miles  to  my  house.  On  May  30  girth 
still  32  in.,  but  no  sign  of  ascites,  no  oedema  of  legs,  and  liver  a  little 
smaller.  He  was  now  ordered  nitro-muriatic  acid,  bark  and  taraxa- 
cum, with  aperients,  and  he  went  to  Devonshire.  From  this  time  there 
was  no  return  of  the  dropsy,  and  he  steadily  improved  ;  in  IS^ovember 
he  weighed  more  than  ever  he  had  done  in  his  life.  On  March  17, 
1874,  liver  scarcely  exceeded  normal  dimensions.  In  October  1874  he 
returned  to  Tirhoot  in  India,  where  he  remained  nntil  following  April ; 
and  on  June  11,  1875,  when  I  last  saw  him,  he  was  still  in  good  health, 
free  from  dropsy,  and  liver  of  about  natural  size. 


Case  LII. — Cirrhotic  Enlargement  of  Liver — Ascites — Good  Effects  of 

Treatment. 

On  March  29, 1873,  I  was  consulted  by  Capt.  M.,  aged  40,  of  R.I^., 
on  account  of  enlargement  of  liver  and  ascites.  He  was  a  short  spare 
man,  had  been  long  on  the  Indian  seas,  and  had  drunk  freely  of  brandy. 
About  a  year  before,  when  in  China,  he  began  to  have  pain  in  liver  and 
morning  sickness  and  diarrhoea ;  and  at  end  of  J^ovember  1872  abdo- 
men began  to  swell,  until  when  he  left  China  in  February  its  girth  was 
38  in.,  and  the  legs  were  also  swollen.  When  I  saw  him  girth  was  re- 
duced to  32  in.  but  still  much  ascites  ;  liver  8  in.  in  r.  m.  ].,  of  which 
four  inches  below  ribs.  Spleen  hard,  and  somewhat  tender,  also  much 
enlarged.  Heart  sound.  No  albuminuria.  Face  sallow,  with  venous 
stigmata. 

Ordered  to  abstain  from  stimulants  ;  Carlsbad  salt  every  morning ; 
blue  pill,  squill,  and  digitalis  twice  daily  ;  and  a  mixture  of  iron  and 
nitrous  ether ;  and  on  April  9  ordered  to  rub  red  iodide  of  mercury  oint- 


144  ENLARGEMENTS    OF    THE    LIVER.  lect.  iv. 

ment  every  night  over  liver.  Under  this  treatment  he  slowly  improved, 
and  on  April  15  no  fluid  in  peritoneum  ;  girth  of  abdomen  29  in.  ;  liver 
in  r.  m.  1.  7-5^  in.  During  summer  he  drank  waters  at  Hombnrg  for 
five  weeks,  and  on  Aug.  20  liver  in  r.  m.  1.  6^  in.,  and  could  walk 
several  miles  without  any  oedema  of  legs.  From  this  time  he  felt  fairly 
well  until  October  1874,  when  he  had  again  uneasiness  about  liver  with 
loss  of  appetite  and  diarrhoea.  For  these  symptoms  he  consulted  a 
medical  man,  who  prescribed  astringents  and  opium  with  port  wine, 
and  after  a  fortnight  abdomen  again  swelled.  On  Dec.  14  much 
ascites  and  enlargement  of  abdominal  veins  ;  girth  of  abdomen  34^  in. ; 
legs  oedematous ;  bowels  costive ;  occasional  retching ;  liver  6  in. 
Port  wine  was  at  once  stopped  ;  Carlsbad  salt  ordered  every  morning  ; 
and  a  mixture  of  iron,  bitartrate  of  potash,  and  digitalis.  Ascites  at 
first  increased,  and  on  Jan.  7  girth  nearly  37  in.  A  mixture  of  per- 
chloride  of  mercury  and  digitalis  was  now  substituted  for  the  iron  &c. 
Under  this  treatment,  modified  somewhat  from  time  to  time,  great  im- 
provement again  took  place  ;  urine  became  very  copious  ;  and  on  May 
6,  girth  29  in.,  no  ascites,  and  liver  in  r.  m.  1.  6  in.,  of  which  2  in. 
below  ribs.  He  again  went  to  Homburg  for  five  weeks,  and  on  his 
return  on  July  14,  1875,  he  appeared  to  be  in  excellent  health,  without 
an}'  sign  of  dropsy,  but  liver  still  6  in.  in  r.  m.  1.  and  hard. 

Case  LIU. — Cirrhotic  Enlargement  of  Liver. — Ascites  and  Albuminuria — 
Weak  Heart — Good  effects  of  Treatment. 

On  April  15,  1873,  I  was  consulted  by  Mr.  James  V.,  aged  56,  on 
account  of  disease  of  liver  and  dropsy.  He  was  a  large  corpulent 
man,  who  had  been  a  free  liver,  and  had  drunk  much  wine  and  spirits. 
Seven  years  before,  he  had  an  attack  of  congestion  of  liver  and  had 
passed  much  blood  per  anum.  For  years  he  had  had  occasionally 
slight  swelling  of  legs,  but  one  month  before  I  saw  him  abdomen  began 
to  swell,  after  which  legs  increased  rapidly.  For  six  months  before 
abdomen  began  to  swell,  had  suffered  from  dyspeptic  symptoms  and 
despondency.  Liver  very  large  (8  in.  in  r.  m.  1.)  hard  and  uneven  ;  much 
ascites ;  girth  48  in.  ;  enormous  swelling  of  penis  and  scrotum ;  gi'eat 
oedema  of  legs,  with  numerous  large  ulcers  ;  urine  contained  |  albumen 
and  hyaline  casts  ;  heart's  sound  weak,  but  no  bellows-murmur. 

Stimulants  were  restricted  to  a  pint  of  hock  or  claret  daily ; 
patient  was  oidered  a  black  draught  with  jalapine  every  morning,  and 
a  mixture  of  bitartrate  of  potash,  squill,  and  digitalis.  Under  this 
treatment,  modified  from  time  to  time,  and  with  occasional  courses  of 
iron,  great  improvement  took  place.  Urine  became  copious  and  free 
from  albumen  ;  ascites  and  dropsy  of  legs  disappeared  ;  and  liver  was 
reduced.  On  June  3  girth  of  abdomen  only  40^  in.,  and  on  July  29, 
39^  in.  For  many  months  after  this,  patient  enjoyed  good  health  and 
went  about  town,  although  he  was  less  prudent  than  he  ought  to  have 


INTERSTITIAL    HEPATITIS. 


145 


been.  There  was  occasionally  a  return  of  albuminuria,  and  once  or 
twice  urine  contained  much  sugar  and  specific  gravity  rose  to  nearly 
1040  ;  but  usually  urine  contained  neither  sugar  nor  albumen,  and 
specific  gravity  was  under  1020.  In  July  1874  there  was  a  return  of 
ascites,  and  girth  of  abdomen  rose  to  44  in.  ;  it  again  disappeared 
Tinder  similar  treatment,  and  on  Oct.  18  girth  only  40  in.  In  January 
1876  there  was  again  a  slight  and  temporary  return  of  ascites,  brouo-ht 
on  apparently  by  imprudence  in  diet.  In  August  1876  he  had  another 
more  severe  attack  of  ascites  and  dropsy  of  legs  ;  but  under  use  of 
elaterium  and  diuretics  this  completely  disappeared,  and  by  middle  of 
October  patient  was  walking  about  London,  with  a  good  appetite  and 
free  from  dropsy  and  albuminuria,  but  with  a  large  hard  liver  stiU 
reaching  almost  to  umbilicus. 


Case  LIV. — Large  smooth  Cirrhotic  Liver  simulating  Waxy  Disease — 
Ascites — Persistent  Diarrhoea — Death. 

Elizabeth  R ,  aged  40,  adm.  into  St.  Thomas's  Hosp.  Sept.  11, 

1875.  I^othing  remarkable  in  family  history.  Married  ;  five  living 
children  from  16  to  5  ;  three  miscarriages,  first  12  months  after  mar- 
riage, a  three  months  foetus ;  last,  four  months  before  admission.  General 
ichthyosis,  but  no  history  of  syphilis.  Habits  not  very  temperate  ; 
admitted  to  1^  pt.  beer  daily,  besides  some  spirits  ;  had  suffered  from 
morning  sickness  independently  of  pregnancies.  Nine  months  before 
admission,  vomiting  became  more  frequent ;  had  great  pain  across 
stomach  and  in  back,  with  persistent  diarrhcea,  cough,  loss  of  appetite 
and  flesh,  and  abdomen  began  to  swell. 

Remained  in  hospital  until  Oct.  25,  and  during  this  time  conditiou 
was  as  follows  : — Emaciated  ;  venous  stigmata  on  cheeks  ;  jaundiced 
tint  of  conjunctivae;  abdomen  enlarged,  measuring  39  in.  at  umbilic  as- 
liver  much  enlarged,  measuring  9  in.  in  r.  m.  1.,  and  lower  maro-in  felt 
hard,  sharp,  and  even,  below  umbilicus ;  surface  smooth ;  moderate 
ascites  ;  frequent  vomiting  and  constant  diarrhoea  ;  no  sign  of  car- 
diac disease,  but  slight  dulness  and  tubular  breathing  at  apex  of  rio-ht 
lung ;  temp,  at  night  usually  101°  ;  occasional  attacks  of  profuse 
epistaxis.  N'o  albuminuria.  On  leaving  hospital,  seemed  better  ;  no 
ascites  and  no  diarrhoea. 

One  month  after  leaving  hospital  abdomen  began  to  swell  again. 
Towards  end  of  January  1876  diarrhoea  returned,  and  on  Feb.  29 
patient  was  readmitted  into  hospital.  Her  condition  was  as  follows. 
Very  weak  and  emaciated  ;  girth  of  abdomen  at  umbilicus  37^  in.  • 
liver  still  very  large,  measurin  in  r.  m.  1.  9^  in.,  and  extendino-  from 
nipple  to  belovp-  umbilicus ;  surface  hard  and  slightly  tender,  generally 
smooth,  but  a  large  projecting  mass  felt  in  epigastrium :  spleen  en- 
larged ;  moderate  ascites ;  constaut  diarrhoea,  8  or  10  watery  motions, 
without  pain,  daily  ;  no  vomiting ;  tongue  unnaturally  red  and  clean  • 

L 


146  ENLARGEMENTS    OF    THE    LIVER.  lkct.  it. 

appetite  bad.  Sallow  and  anaemic  ;  no  decided  jaundice,  but  urine 
contained  bile-pigment  and  ^  albumen.  Almost  constant  epistaxis  and 
great  fetor  of  breath.     Pulse  120.     Heart  healthy. 

Patient  was  ordered  milk  diet,  and  a  mixture  of  bismuth  and 
opium,  and  subsequently  pernitrate  of  iron,  but  she  became  daily  worse. 
On  March  2  she  vomited  about  a  pint  of  dark  blood ;  the  ascites 
diminished  slightly,  but  the  diarrhoea  and  epistaxis  persisted,  and  on 
Marcb  16  she  died  from  exhaustion. 

Autofsy. — Six  pints  of  ascitic  fluid  in  peritoneum.  Liver  very  large, 
weighed  74  oz.,  firmly  adherent  to  transverse  colon,  stomach,  &c. 
Capsule  greatly  thickened,  and  on  upper  surface  two  loculated  cj'-sts  of 
ascitic  fluid ;  lower  margin  rounded  ;  typical  cirrhotic  structure  on 
section ;  no  amyloid  reaction.  Spleen  12^  oz.,  congested.  Kidneys 
firm,  but  yielded  no  amyloid  reaction.     Right  lung  adherent. 

Case  LV.  appeared  to  be  an  example  of  great  enlargement  of 
the  liver  from  interstitial  hepatitis  consequent  on  mitral  disease. 

Case  LV. — Great  E7ilargeinent  of  Liver  and  Ascites,  secondary  to  Mitral 

Disease. 

Edwin   F ,  aged  11,   adm.  into  St.   Thomas's  Hosp.   Nov.   3, 

1871.  Had  enjoyed  good  health  till  last  July,  when  he  was  laid  up  for 
several  weeks  with  a  severe  attack  of  rheumatic  fever,  and  since  then 
he  had  suflPered  from  palpitations  and  dyspnoea.  On  admission  heart 
greatly  enlarged,  measuring  3^  in.  transversely,  its  apex  beating  be- 
tween 6th  and  7th  ribs  outside  nipple.  At  apex  was  a  loud  whistling 
systolic  bellows-murmur,  heard  also  at  lower  angle  of  left  scapula  and 
in  fact  all  over  chest.  Pulse  108,  small  and  weak.  Occasional  cough, 
but  langs  healthy.  Liver  slightly  enlarged.  Slight  oedema  of  legs. 
Albumen  (|)  in  urine. 

Was  ordered  digitalis  and  iron,  and  on  Nov.  9  appearance  greatly 
improved,  and  albumen  disappeared  from  urine. 

On  Dec.  14,  while  still  in  hospital,  was  seized  with  a  second  attack 
of  articular  rheumatism,  which  became  complicated  with  pericarditis 
and  pleuro-pneumonia.  For  several  weeks  he  was  extremely  ill,  and 
the  disappearance  of  the  pericarditis  and  pneumonia  was  followed  by 
a  great  aggravation  of  the  cardiac  symptoms.  On  Jan.  22  transverse 
dulness  of  heart  4  in.,  breath  very  short,  much  cardiac  pain  and  palpi- 
tation ;  considerable  oedema  of  legs  and  some  ascites,  but  no  albumen 
in  urine.  Diuretics  and  iron  were  of  little  use,  and  on  !March  18  both 
legs,  which  were  enormously  enlarged,  were  punctured  with  consider- 
able relief.  On  Ajjril  1  fomentation  of  abdomen  with  infusion  of 
digitalis  four  times  the  PliarmacopaMa  strength  had  the  efPect  of  in- 
creasing flow  of  urine  and  reducing  dropsy.  After  a  few  days,  how- 
ever, dropsy  again  increased  in   abdomen,  until,  on  April  22,  girth  at 


XECT.  IV.  INTERSTITIAL    HEPATITIS.  1 47 

umbilicus  was  33  inches,  but  there  was  little  or  no  oedema  of  leg-s. 
Liver  was  greatly  enlarged,  extending  from  right  nipple  to  umbilicus,  its 
surface  smooth,  hard,  and  slightly  tender  ;  abdominal  veins  enlarged  ; 
no  jaundice  ;  much  albumen  in  urine  ;  dyspnoea  urgent.  By  paracen- 
tesis abdominis  172  oz.  of  fluid  were  now  drawn  off,  with  great 
and  immediate  relief.  The  albuminuria  at  once  ceased;  and  under 
use  of  digitalis  with  other  diuretics,  blue  pill,  purgatives,  and  suljse- 
quently  iron,  ascites  did  not  again  collect ;  liver  diminished  somewhat 
in  size,  and  cardiac  symptoms  improved.  On  Aug.  6  left  hospital  free 
from  dropsy,  and  girth  at  umbilicus  only  25  in. 

Was  again  a  patient  in  hospital  from  Nov.  13  to  Dec.  5,  1872,  with 
albuminuria,  slight  ascites,  (abdomen  measuring  27|  in.)  but  no  oedema 
of  legs.  Under  use  of  blue  pill,  digitalis,  diuretics,  purgatives,  and 
iron,  albuminuria  and  ascites  again  completely  disappeared  ;  and  boy, 
on  leaving  hospital,  went  to  sea-side.     Liver  was  still  large.  ^ 

Cases  LYI.  to  LXI.  are  examples  of  syphilitic  enlargement  of 
tlie  liver  v^^itli  gummata. 

In  Case  LVI.  the  syphilitic  nature  of  the  disease  in  the  liver 
was  not  suspected  during  life.  The  concurrence  of  great 
enlargement  of  the  spleen,  persistent  diarrhoea,  copious  albu- 
minuria without  general  dropsy,  and  great  anasmia,  suggested 
that  the  enlargement  of  the  liver  was  due  to  waxy  disease,  and 
the  ascites  was  referred  to  compression  of  the  portal  vein  by 
lymphatic  glands  enlarged  from  waxy  deposit.  The  profase 
catamenial  discharge  was,  however,  the  only  cause  that  could  be 
assigned  for  waxy  disease.^ 

Case  LVI. — Syphilitic  Hepatitis  and  Gummata  of  Liver — Waxy 
Spleen — Ascites — Diarrhoea — Jaundice. 

Sarah  B ,   aged  25,   was  a  patient  in  Middlesex  Hosp.  from 

April  21  to  June  2,  1868,  for  anaemia,  enlargement  of  liver  and 
spleen,  albuminuria,  ascites,  and  diarrhoea.  Since  first  appearance  of 
catamenia  at  age  of  12,  when  she  had  copious  flooding,  she  had  suf- 
fered from  anaemia  and  chlorosis,  and  she  had  been  much  worse  since 
her  marriage  in  1866.  She  had  never  been  pregnant,  and  after 
most  careful  enquiry  nothing  could  be  elicited  pointing  to  a  syphilitic 
history.  Her  father  had  died  at  40  of  effects  of  an  accident :  her 
mother  and  one  sister  had  died  of  consumption.  At  commencement 
of  1866  abdomen  had  begun  to  swell  and  diarrhoea  set  in.  At  time 
of  admission  girth  of  umbilicus  was  34^  in. ;  hepatic  dulness  in  r. 
m.  1.  rose  to  nipple  and  measured  4|-  in.  ;  vertical  splenic  dulness 
6  in.  ;  urine  contained  ^  albumen ;  bowels  open  ten  to  twelve  times 
1  See  also  Case  LXXXIX.  p.  488,  in  1st  edition. 
L  2 


148  ENLARGEMENTS   OF    THE    LIVER.  lect.  iv. 

a  day.  Heart  elevated  but  healthy.  Under  the  use  of  nitric  acid  and 
opiuna,  diarrhoea  ceased  ;  albumen  was  reduced  to  a  mere  trace,  and 
ascites  disappeared,  although  abdomen  still  measured  33  in. 

Was  ai^ain  a  patient  in  Middlesex  Hosp.  from  Nov.  2  to  Dec.  1, 

1868.  Had  then  slight  jaundice,  distinct  ascites  ;  liver  5  in.  in  r.  m.  1.  ; 
spleen  projected  5  in.  beyond  ribs  ;  6  stools  daily  ;  no  albumen  in 
urine  during  whole  time  ;  but  systolic  murmur  at  base  of  heart.  Was 
again  relieved  by  same  treatment  as  before. 

Was  a  third  time  a  patient   in  hospital,  from  July  9  to  Aug.  10, 

1869.  Still  ascites  and  slight  jaundice.  Liver  dulness  5  in.  and 
spleen  5  in.  beyond  ribs.  Girth  of  abdomen  35^  in.  Urine  contained 
a  trace  of  albumen  ;  8  to  10  stools  daily  ;  menorrhagia  ;  anasarca  of 
legs.  Under  same  treatment  diarrhoea  again  ceased,  and  patient 
gained  flesh  and  strength. 

Was  a  fourth  time  a  patient  in  hospital  with  same  symptoms  from 
Nov.  23,  1869,  to  Jan.  8,  1870.  Girth  of  abdomen  36  in.  ;  7  or  8 
stools  ;  albumen  ^V- 

Soon  after  leaving  hospital  on  Jan.  8,  diarrhoea  returned  and  ab- 
domen became  larger.  Came  several  times  as  an  out-patient,  and  on 
March  17,  1870,  was  admitted  for  a  fifth  time.  Girth  of  abdomen 
was  now  43  in.,  and  corresponding  to  umbilicus  was  a  protrusion  as 
large  as  an  orange,  integuments  of  which  were  red,  thin,  glistening,  and 
tender  ;  but  abdomen  generally  not  tender.  Superficial  veins  of  thorax 
and  abdomen  much  enlarged.  No  appetite  ;  much  flatulence ;  three 
or  four  stools  daily  ;  occasional  retching.  Considerable  dyspnoea ; 
resp.  48,  and  thoracic.  Pulse  108  ;  no  bellows-murmur  with  heart. 
Urine  contained  fully  one-half  albumen  and  some  bile-pigment ;  no 
casts.  Slight  oedema  of  legs.  Marked  chlorosis.  No  jaundice.  All 
treatment  on  this  occasion  proved  useless.  Patient  became  rapidly 
worse.  On  March  21  passed  very  little  urine,  was  restless  and  wan- 
dered ;  on  22nd  unconscious ;  on  23rd  pulse  intermittent  and 
diarrhoea  increased.     On  24th  she  died. 

Auf()2)sy. — No  visible  cicatrices  on  vulva  or  on  vagina,  but  a  deep 
cicatrix  on  anterior  lip  of  uterus.  Peritoneum  contained  100  oz.  of 
clear  yellow  serum,  with  a  few  flakes  of  lymph  ;  entire  membrane 
presented  signs  of  recent  peritonitis,  vessels  being  intensely  injected 
and  intestines  plastered  with  soft  yellow  lymph.  Firm  adhesions  be- 
tween liver  and  diaphragm  and  right  kidney,  &c.  Liver  rather  small,  its 
capsule  thickened  and  its  outer  surface  marked  by  numerous  deep 
cicatrix-like  depressions,  and  on  cutting  into  several  of  these  they 
were  found  to  be  connected  with  characteristic  syphilitic  gummata, 
some  as  large  as  cherries.  Hepatic  tissue  pale  and  friahle,  fatty,  and 
with  no  amyloid  reaction.  Much  fibrous  tissue  in  portal  fissure,  com- 
pressing but  not  obliterating  portal  vein.  Considerable  hypertrophy 
of  connective  tissue  in  interior  of  liver.  Hound  ligament  much  thick- 
ened.    Spleen  30^  oz. ;  capsule  much  thickened  ;  its   tissue  firm  and 


LECT.  IV.                              INTEESTITIAL    HEPATITIS.  I49 

waxy,  with  distinct  amyJoid  reaction.     Kidneys  large  and  pale   (7  oz. 

each),  with  amyloid  reaction  of  small  arteries.  No  ulceration  and  no 
amyloid  reaction  of  intestines. 


Case  LYII. — SyphiUHc  E7ilargement  (Gummata)  of  Liver — Gummafa  in 
one  arm — Periostitis  of  one  tibia. 

On  July  28,  1875,   I  was  consulted  by  Mrs.  R ,  aged  37,  on 

account  of  a  tumour  of  liver,  regarding  which  different  opinions  had 
been  expressed  by  the  many  medical  men  whom  she  had  seen.  Some 
had  said  that  it  was  hydatid  ;  others,  abscess  ;  others,  cancer ;  and  one 
distinguished  physician  had  pronounced  it  an  adenoid  tumour.  The 
liver  was  very  large,  extending  from  nipple  to  navel,  and  portion 
below  liver  bulged  forward  and  was  very  soft  and  elastic  but  painless  ; 
its  surface  was  distinctly  nodulated,  one  nodule  in  epigastrium  very 
like  cancer,  most  prominent  parts  being  the  softest ;  there  was  jaun- 
dice, which  came  and  went,  and  was  sometimes  attended  by  white 
stools  ;  no  ascites ;  spleen  much  enlarged,  projecting  four  inches  be- 
yond ribs.  No  albuminuria.  Slight  oedema  of  legs,  and  some  perios- 
titic  swelling  of  left  tibia,  not  of  right.  Temp,  normal,  appetite  good. 
History  was  this  : — Mother  had  died  of  cancer  of  uterus.  Married  16 
years  ;  no  children  ;  one  doubtful  abortion  six  weeks  after  marriage, 
but  with  this  exception  never  pregnant.  More  than  four  years  ago 
began  to  have  a  vaginal  discharge,  for  which,  on  medical  advice,  she 
took  much  mercury  and  was  salivated.  Two  years  ago  noticed  first 
one,  and  then  a  second,  small  lump  below  right  ribs  in  front.  These 
lumps  had  increased  steadily  from  first,  but  more  rapidly  of  late. 

Although  it  was  not  supposed  that  the  tumour  contained  fluid,  it 
was  determined  to  remove  all  doubt  by  making  an  exploratory  punc- 
ture. This  was  done,  but  only  blood  escaped.  Nitro-muriatic  acid, 
nux  vomica,  and  saline  aperients  were  ordered.  Under  this  treat- 
ment she  felt  better  and  stronger,  and  there  was  no  increase  of  swell- 
ing. On  Oct.  31  she  vomited  a  little  blood,  and  for  several  days  after- 
wards she  had  much  nausea  and  was  deeply  jaundiced.  About  this 
time  first  observed  a  lump  about  size  of  half  an  orange  in  soft  parts  of 
left  upper  arm.  This  increased  slightly  and  became  red  and  soft  in 
centre,  and  very  painful,  and  for  this  I  was  again  consulted  on  Jan.  18, 
1876.  Iodide  of  potassium  was  prescribed,  but  two  days  afterwards 
patient  had  an  attack  of  very  profuse  haemorrhage  from  stomach  and 
bowels,  and  medicine  was  suspended.  Swelling  in  arm  increased,  and 
on  Feb.  7  a  slough,  size  of  half-a-crown,  had  formed  in  centre  of  lump, 
circumference  of  which  was  still  very  hard  and  tender.  Iodide  of 
potassium  was  resumed  (gr.  iij  ter  die).  On  Feb.  28,  slough  sepa- 
rating ;  a  distinct  periostitic  node  on  left  tibia ;  no  return  of  haemor- 
rhage ;  liver  apparently  not  larger  than  six  months  before ;  girth  over 
most  prominent  part  34^  in.  5  appetite  good,   but  painful  distension 


150  ENLARGEMENTS    OF   THE    LIVER.  lect.iv. 

after  food.  No  albumen  in  urine.  "Was  ordered  iodide  of  potassium, 
ten  grains,  with  sarsaparilla,  three  times  daily.  Under  this  treatment, 
alternated  occasionally  with  small  doses  of  perchloride  of  mercury  and 
bark,  patient  greatly  improved.  On  March  27  slough  had  separated 
from  arm  and  sore  was  healing,  jaundice  less,  and  girth  only  33|-  in. 
On  May  2  sore  in  arm  quite  healed,  leaving  deep  cicatrix ;  but  severe 
pcriostitic  pains  in  right  ulna  and  fingers,  and  in  right  tibia.  On 
June  1  periostitic  pains  gone  ;  scarcely  any  jaundice  ;  up,  and  going 
about.  July  19  :  has  driven  out  five  or  six  times  ;  gaining  flesh  ; 
girth  35  in,  ;  severe  periostitic  pain  over  right  elbow.  July  20 : 
something  seemed  to  burst  inside,  and  she  vomited  a  quantity  of 
yellowish  matter,  which  was  not  preserved.  Had  nausea  for  several 
days  after,  but  then  continued  to  improve.  Sept,  26  :  liver  decidedly 
smaller  ;  girth  only  o3|-  in.,  although  she  has  grown  very  much  stouter. 
Spleen  not  diminished  in  size.  No  jaundice  ;  appetite  good.  Still 
has  periostitic  pains  in  right  ulna  preventing  sleep. 

Case  LVIII. —  Sijijldlltic  Enlargement  of  Liver- — Gumma  in  left  leg. 

Mr.  J ,  about  47,  consulted  me  for  first  time  on  May  4,  1874. 

About  16  years  before  he  had  syphilis.  The  sore  was  slight,  and  he  does 
not  remember  having  had  constitutional  symptoms.  Six  years  after- 
wards he  married  ;  his  wife  had  no  children  or  miscarriages.  In  1871 
he  began  to  feel  stuffed  up  in  nose,  and  soon  after  he  noticed  an  offensive 
discharge,  with  occasional  clots  of  blood,  from  nose.  The  discharge 
also  passed  backwards.  After  ten  months  a  piece  of  bone,  size  of 
sixpence,  came  away  from  right  nostril  and  discharge  ceased.  About 
same  time  gums  were  in  a  very  bad  state  and  he  had  five  teeth  drawn. 
Soon  after  this  he  got  better,  and  remained  well  until  Nov.  1873, 
when  one  day  after  lunch  he  got  squeamish,  had  pain  in  region  of 
liver  with  slight  jaundice,  and  for  five  weeks  was  unable  to  go  to  busi- 
ness. Ever  since  he  had  suffered  from  flatulence  and  other  symptoms 
of  indigestion,  and  also  from  piles  ;  but,  although  he  had  been  in 
habit  of  drinking  a  good  deal  of  whisky,  he  never  had  nausea  or  morn- 
ing sickness,  and  had  always  a  good  appetite  for  breakfast.  There 
was  dilatation  of  capillaries  of  cheeks,  but  no  jaundice.  Liver  very 
large,  measuring  8  in.  in  r.  m.  1.  ;  enlargement  uniform ;  smooth,  hard, 
and  painless.  Spleen  also  somewhat  enlai-ged;  no  ascites.  Tongue 
preternatu rally  clean  and  red  ;  bowels  usually  costive.  Urine  1024, 
usually  loaded  with  lithates,  but  free  from  albumen.  Pulse  96 ; 
heart  normal. 

He  was  ordered  to  abstain  from  stimulants,  except  a  little  claret 
and  water,  to  take  a  dose  of  Carlsbad  salt  every  alternate  morning, 
and  a  mixture  of  perchloride  of  mercury  and  chloride  of  ammonium 
three  times  a  day.  Under  this  treatment  urine  became  copious  and 
clear,  symptoms  greatly  improved,  and  liver  was  slightly  reduced  in 


LECT.  IV.  INTERSTITIAL    HEPATITIS.  15  I 

size.  On  Oct.  24  it  measured  only  7^  in.  in  r.  m.  1.,  but  there  was 
a  small  painful  ulcer  on  left  tonsil,  and  often  in  morning  a  little 
blood  was  discbarged  from  nose.  After  this  he  took  iodide  of 
potassium  occasionally,  but  he  always  felt  better  while  taking  the 
perchloride  of  mercury.  In  Dec.  1874  he  first  noticed  a  lump  in 
middle  of  left  leg  over  tibia,  but  quite  unconnected  with  bone.  This 
increased  to  size  of  an  egg  and  softened  ;  in  May  1875  it  was  opened ; 
no  pus,  but  much  clotted  blood,  escaped.  Wound  was  many  months 
in  healing,  and  patient  was  unable  to  walk  much  on  account  of  pain 
in  left  ankle.  On  healing,  a  deep  scar  remained,  covered  by  a  scab, 
and  surrounded  by  considerable  induration.  In  Feb.  1876  this 
was  seen  by  Sir  James  Paget,  who  at  once  pronounced  it  to  be  a 
syphilitic  gumma.  Liver  still  large,  but  measurement  in  r.  m.  1.  not 
more  than  6^  in. ;  surface  smooth.  Still  has  pain  about  left  ankle 
which  prevents  him  walking  much,  but  appetite  and  digestion  are 
good.  He  was  ordered  a  mixture  of  perchloride  of  mercury  with  bark  ; 
and  in  October  (1876)  I  heard  that  his  health  had  greatly  improved. 

Case  LIX. — Enlarged  Fibrous  Syphilitic  Liver  ivith  Gummata — Ascites. 

Harriet  E. ,    aged   28,  adm.  into  St.  Thomas's  Hosp.  Feb.  1, 

1875.  Nothing  noteworthy  in  family  history.  Had  enjoyed  good 
health  until  three  years  before  admission,  when  she  had  for  some 
weeks  an  obscure  attack  of  pain  and  swelling  in  lower  part  of  abdo- 
men;  but  after  this  got  quite  well  and  married  in  Jan.  1873.  One 
miscarriage,  but  no  living  child.  Early  in  1874  began  to  suffer  from 
dry  cough,  flatulent  distension  of  abdomen,  and  retching  from  slight 
causes  ;  but  no  morning  sickness,  and  habits  temperate.  In  November 
.  1874  abdomen  became  swollen  and  painful ;  and  since  then  excessive 
vomiting  brought  on  by  sight  or  smell  of  food ;  increase  of  cough  ; 
loss  of  appetite ;  emaciation  ;  and  attacks  of  abdominal  pain,  some- 
times so  severe  as  to  keep  her  in  bed  for  a  week. 

On  admission,  emaciated  and  countenance  expressive  of  pain  ;  no 
jaundice  or  venous  stigmata  on  cheeks ;  pain  and  tenderness  of  abdo- 
men, which  measured  at  umbilicus  48^  in.  Much  ascites  ;  abdominal 
veins  but  slightly  dilated  ;  neither  liver  nor  spleen  could  be  felt,  but 
upper  margin  of  hepatic  dulness  reached  almost  to  nipple  ;  tongue  too 
clean  and  red ;  frequent  retching ;  bowels  costive.  Urine  contained 
phosphates,  but  free  from  lithates  or  albumen.  Pulse  96,  small  and 
feeble  ;  apex  of  heart  elevated,  but  no  abnormal  murmur.  Frequent 
dry  cough  ;  respiration  thoracic  and  somewhat  laboured  ;  but  lung 
signs  normal.     Slight  pitting  of  legs.      Temp.  99°. 

Was  treated  with  purgatives  and  diuretics,  including  digitalis  ;  but 
as  no  improvement  resulted,  and  patient  was  suffering  great  pain  and 
distress  of  breathing  from  abdominal  distension,  paracentesis  was 
performed  on  Feb.  6,  and  19  pints  removed  of  straw-coloured   serum  ; 


152  ENLAEGEMENTS    OF   THE    LIVER.  lect.  iv. 

sp.  gr.  1016.  Operation  gave  great  relief.  After  removal  of  fluid, 
upper  margin  of  hepatic  dulness  still  nearly  reached  nipple.  Lower 
margin  of  liver  could  be  felt  projecting  more  than  three  inches 
beyond  ribs  in  r.  m.  1.,  hard,  indented,  and  tender,  but  surface 
smooth.  Girth  36  in.  On  Feb.  10  was  ordered  iodide  and  citrate  of 
potash,  with  digitalis  and  decoction  of  broom- tops ;  and  for  this  on 
Feb.  20  a  mixture  of  perchloride  of  mercury,  squills,  and  digitalis  was 
substituted.  Fluid  gradually  re-accumulated,  and  on  Feb.  24  girth 
43  in.  ;  urine  scanty;  paracentesis;  18  pints  drawn  off;  sp.  gr.  1015. 
Operation  again  gave  immediate  I'elief,  and  on  both  occasions  was 
followed  by  great  increase  in  flow  of  urine.  From  March  3  to  13 
bad  erysipelas  of  face  and  scalp  spreading  to  abdomen,  during  which 
pulse  rose  to  160,  temperature  to  104°,  dry  tongue,  and  much  delirium. 
After  this  extreme  prostration,  large  abscesses,  one  containing  more 
than  a  pint  of  pus,  formed  beneath  skin  on  different  parts  of  body, 
and  girth  of  abdomen  increased  to  45|^  in.  On  April  2,  five  pints,  and 
on  9th,  24  pints  of  fluid  (sp.  gr.  1015)  drawn  off  by  paracentesis. 
Died  from  exhaustion  on  April  27. 

Autopsy. — Peritoneum  contained  24  pints  of  serum.  Liver  en- 
larged ;  weighed  62  oz.  ;  firmly  adherent  to  all  adjacent  organs ;  cap- 
sule  thickened  ;  substance  indurated  from  interstitial  hepatitis  ;  nume- 
rous firm  syphilitic  gummata,  some  as  large  as  cherries,  mainly  distri- 
buted along  course  of  portal  vein  and  of  its  branches,  some  of  them 
forming  projections  from  surface  of  liver.  Portal  vein  in  fissure  of 
liver  much  dilated.  Spleen  14  oz.;  firm.  No  amyloid  reaction  in  liver, 
spleen,  or  kidneys.  Kecent  pleurisy  on  both  sides  ;  both  lungs  oede- 
matous. 

VII.    INFLAMMATION    OP    THE    BILIARY    PASSAGES. 

This  condition  is  usually  associated  v^^ith  more  or  less  con- 
gestion of  the  hepatic  tissue,  and  accordingly  its  clinical 
characters  are  those  of  congestion,  which  I  need  not  recapitu- 
late, with  those  peculiar  to  catarrh  of  the  bile-ducts  and  gall- 
bladder superadded.     Thus  we  have — 

1.  Enlargement  of  the  liver,  which,  like  that  from  congestion, 
is  uniform  in  every  direction,  and  rarely  very  great ;  but  which 
is  sometimes  accompanied  by  enlargement  of  the  gall-bladder 
in  the  form  of  a  more  or  less  pyriform  tumour  projecting  from 
the  anterior  margin  (see  fig.  16,  page  163).  In  some  cases  no 
enlargement  can  be  made  out. 

2.  The  portion  of  liver  projecting  below  the  right  ribs  is 
smooth  on  palpation. 

3.  There  is  at  first  a  feeling  of  tightness  and  distension  in  the 
right  hypochondrium,  with  tenderness  on  pressure,  particularly 


LECT.  IV.  INFLAMMATION    OF    BILE-DUCTS.  1 53 

over  the  enlarged  gall-bladder.  Sometimes,  however,  there  is  little 
or  no  pain  or  uneasiness.    The  pulse  is  usually  abnormally  slow. 

4.  Inasmuch  as  the  bile-ducts  are  obstructed  from  the 
tumefaction  of  the  mucous  membrane,  as  well  as  from  the 
injflammatory  products  thrown  off  from  its  free  surface,  the 
jaundice,  after  a  day  or  two,  is  much  more  intense  than  in 
simple  congestion,  and  the  motions  contain  no  bile. 

5.  Here,  again,  the  circumstances  under  which  the  attack 
occurs  are  of  great  assistance  in  diagnosis. 

a.  In  a  large  majority  of  cases  the  attack  is  preceded  by 
symptoms  of  catarrh  of  the  stomach  and  duodenum.  The 
inflammation,  in  fact,  commences  in  the  mucous  membrane  of 
the  digestive  canal,  and  extends  thence  to  the  common  bile- 
duct.  Accordingly  there  are  to  be  noted,  in  the  first  place,  a 
furred  tongue,  loss  of  appetite,  flatulence,  nausea  or  vomiting, 
pain  and  tenderness  at  the  epigastrium,  and  sometimes  diarrhoea, 
these  symptoms  being  often  accompanied  by  slight  pyrexia. 
After  a  few  days  or  longer,  jaundice  appears,  and  the  fever,  if 
present,  may  subside,  although  the  dyspeptic  symptoms  remain. 
Attacks  of  this  sort  are  very  common  in  children  as  the  result 
of  eating  indigestible  food,  or  of  a  surfeit ;  and,  in  that  case 
the  jaundice  and  other  symptoms  usually  subside  at  the  end  of 
ten  days  or  three  weeks. 

h.  Catarrh  of  the  bile-ducts  (like  catarrh  of  the  bronchial  tubes) 
is  not  uncommon  in  persons  of  more  advanced  age  of  a  gouty 
constitution,  and  more  than  once  I  have  met  with  cases  of  this 
description,  where  the  frequent  vomiting,  the  emaciation,  and 
the  jaundice  persisting  ior  many  weeks,  have  led  to  the  sus- 
picion of  cancer,  but  have  soon  subsided  under  the  use  of 
purgatives  with  colchicum  and  alkalies. 

c.  Catarrh  of  the  bile-ducts  is  one  of  the  diseases  of  the 
liver  consequent  on  syphilis.  The  jaundice  which  is  not  un- 
common during  what  is  known  as  the  secondary  stage  is  usually 
due  to  this  cause,  and  it  is  especially  in  cases  of  this  nature  that 
acute  atrophy  of  the  liver  is  apt  to  supervene. 

d.  Inflammation  of  the  biliary  passages  may  be  secondary  to 
congestion  or  other  diseases  of  the  liver,  and  then  its  symptoms 
may  be  persistent.  It  is  probable  that  catarrh  of  the  ducts 
may  not  onlj^  excite  congestion  of  the  hepatic  tissue,  but  may 
result  from  it.  In  any  case,  where  congestion  of  the  liver  is 
developed  under  the  circumstances  already  mentioned,  and 
where,  in  addition  to  the  symptoms  of  simple  congestion,  there  is 


154  ENLAKGEMENTS    OF    THE    LIVER.  tECT.  iv. 

intense  jaundice,  with  an  absence  of  bile  from  the  motions,  we 
ma}^  infer  that  there  is  catarrh  of  the  ducts  as  well  as  congestion. 
Other  diseases  of  the  liver,  also,  such  as  the  waxy  liver  and 
hydatid  tumour,  are  occasionally  complicated  with  catarrh  of 
the  ducts ;  and  in  this  way  jaundice  may  appear  in  the  course 
of  diseases  of  the  liver  in  which  it  is  usually  absent.  In  another 
lecture  (Lect.  VII.)  I  shall  have  occasion  to  mention  an  example 
of  enlargement  of  the  liver  from  tubercular  deposit  where  the 
jaundice  was  apparently  due  to  inflammation  of  the  common 
bile-duct. 

e.  Inflammation  of  the  bile-ducts  and  gall-bladder  may  be 
due  to  the  irritation  of  gall-stones  or  of  other  foreign  bodies. 
Under  these  circumstances  it  will  usually  be  distinguished  by 
a  previous  history  of  biliary  colic,  which,  however,  was  notably 
absent  in  the  case  of  one  patient  who  lately  died  in  the  wards 
(Case  LXV.). 

/.  Certain  poisons,  such  as  those  of  pyaemia  and  phosphorus, 
have  been  stated  by  Yirchow  to  excite  catarrh  of  the  bile-ducts.^ 
The  cause  of  that  form  of  catarrh  of  the  bile-ducts  known  as 
'  epidemic  jaundice  '  is  probably  some  poison  contained  in  iihe 
air  or  in  drinking  water. 

Speaking  generally,  it  may  be  said  that  in  young  people 
catarrh  of  the  bile-ducts  is  the  most  common  cause  of  jaundice  ; 
whereas  in  persons  of  middle  or  advanced  life,  if  we  can  exclude 
syphilis  and  a  gouty  habit,  jaundice  is  probably  due  to  some 
other  cause  than  catarrh. 

Treatment. — The  rules  already  laid  down  for  the  treatment 
of  congestion  of  the  liver  are  also  applicable  to  catarrh  of  the 
bile-ducts.     Little  more  need  be  added  except  that — 

1.  Leeches  and  cupping  are  less  necessary  in  simple  catarrh. 
In  most  cases  sinapisms  and  warm  fomentations,  with  purga- 
tives, alkalies,  and  chloride  of  ammonium,  suffice  for  subduing 
the  disease.  The  propriety  of  employing  local  depletion  must 
be  decided  by  the  degree  of  pain  and  amount  of  congestion 
existing  in  each  case. 

2.  When  there  is  reason  to  suspect  that  the  affection  is  of  a 
gouty  nature,  great  benefit  will  often  be  derived  from  the  ad- 
dition of  colchicum  and  iodide  of  potassium  to  the  remedies 
already  mentioned.  In  these  cases  also  it  will  be  necessary  to 
adopt  such  measures  as  are  calculated  to  correct  that  disordered 
condition  of  the  digestion,  which,  if  neglected,  will  before  long 
lead  to  a  recurrence  of  the  hepatic  attack. 

'  Virchow's  Arch.  1865,  xxx.  lift.  1. 


lECT.  IT,  INFLAMMATION    OF    BILE-DUCTS.  155 

3.  In  syphilitic  cases  the  most  useful  remedies  are  the  per- 
chloride  of  mercury  and  chloride  of  ammonium,  in  conjunction 
with  purgatives. 

4.  The  treatment  must  occasionally  be  modified  by  the 
presence  of  other  diseases  of  the  liver,  of  which  the  catarrh  of 
the  bile-ducts  is  merely  a  complication. 

When  T  come  to  lecture  on  Jaundice,  I  shall  have  to  return 
to  the  subject  of  catarrh  of  the  bile-ducts  (Lect.  X) ;  but  in 
the  meantime  I  would  direct  your  attention  to  the  follow- 
ing cases  of  painful  enlargement  of  the  liver  accompanied  with 
jaundice,  apparently  due  to  catarrh  of  the  ducts. 


Case   LX. — Painful  Enlargement  of  Liver,  ivith  Jaundice  due  to  Catarrh 

of  Bile-ducts. 

Elizabeth    L ,    aged    21,    a   maid-servant,    was   admitted   into 

Middlesex  Hosp.  on  Dec.  7,  1866.  For  nine  months  she  had  been 
weakly  and  unable  to  take  a  place,  and  had  also  suffered  from  dys- 
peptic symptoms.  Ten  days  before  admission,  at  the  cessation  of  last 
catamenial  period,  which  had  its  usual  duration,  she  had  been  seized 
with  great  nausea  and  vomiting,  but  she  had  no  diarrhoea.  Five  days 
after  this  she  began  to  complain  of  pain  and  tenderness  in  region  of 
liver,  but  pain  was  never  very  severe.  About  same  time  jaundice 
made  its  appearance,"  which  increased  in  intensity,  and  was  accompa- 
nied by  much  itchiness  of  skin. 

On  admission,  deep  jaundiced  colour  of  entire  skin  and  conjunc- 
tivEe  ;  urine  very  dark,  and  gave  characteristic  reaction  of  bile-pig- 
ment ;  tongue  thickly  coated  ;  no  appetite,  but  vomiting  and  pain  in 
side  had  much  subsided  ;  lower  margin  of  liver  was  ascertained  to 
project  about  an  inch  below  margin  of  ribs  in  right  mammary  line, 
and  here  there  was  slight  tenderness  on  pressure  ;  bowels  rather  con- 
stipated ;  motions  clay-coloured,  without  a  vestige  of  bile-pigment ; 
pulse  100  ;  skin  rather  hot  (temp.  100°  F.)  ;  respiration  slow  and  easy ; 
physical  signs  of  heart  and  lungs  normal. 

The  treatment  consisted  in  the  frequent  administration  of  saline 
purgatives  (sulphate  of  magnesia),  and  a  blue  pill  occasionally  at  bed- 
time, together  with  the  application  of  mustard  and  linseed  poultices  to 
region  of  liver. 

Bowels  were  freely  purged,  and  on  Dec.  17  the  symptoms  had  con- 
siderably improved ;  pulse  had  fallen  to  68 ;  tongue  clean ;  neither 
nausea  nor  vomiting  ;  appetite  returning  ;  urine  contained  less  bile- 
pigment.  No  change,  however,  had  taken  place  in  colour  of  skin  and 
conjunctivae,  which  were  still  deeply  jaundiced.  An  alkaline  mixture, 
containing  bicarbonate  of  soda,  chloric  ether,  and  tincture  of  orange, 


156  ENLARGEMENTS    OF    THE    LIVER.  lect.  iv, 

was  now  substituted  for  the  sulphate  of  magnesia ;  a  purgativ^e  was 
still  given  occasionally,  and  patient  had  a  warm  bath  twice  a  week. 

On  Dec.  20  jaundiced  tint  was  first  noticed  to  be  giving  way,  and 
from  this  date  it  gradually  faded  until  Jan.  7,  18G7,  when  it  had  quite 
disappeared.  A  tonic  mixture  with  nitric  acid  and  quinine  was  now 
ordered,  and  on  Jan.  22  patient  left  the  hospital  in  good  health. 

The  following  cases  are  cited  as  illustrations  of  catarrh  of 
the  bile-ducts  occurring  in  gout}'  individuals.  (See  also  Case 
CXXI.). 

Case  LXI. — Gouty  Dyspepsia — Enlargement  of  Liver,  and  Jaundice  from 
Catarrh  of  Bile-duds. 

In  autumn  of  1865  I  was  consulted  by  Mr.  C.  D ,  a  gentleman 

aged  30.  His  father  had  been  a  martyr  to  gout,  and  a  younger  brother 
had  suffered  from  it  early  in  life.  He  had  never  had  well-marked  gout 
himself,  but  he  had  long  been  liable  to  gastric  derangements  charac- 
terised by  nausea  and  flatulence  and  transient  pains  in  small  joints. 
About  three  weeks  before  I  saw  him  he  had  been  seized  about 
an  hour  after  dinner,  with  a  pain  at  the  epigastrium,  followed 
by  vomiting  and  nausea.  A  few  days  later  jaundice  appeared,  and 
gradually  increased  in  intensity  ;  the  nausea  continued  without  vomit- 
ing, and  patient  became  much  emaciated.  On  examination  I  found 
lower  margin  of  liver  projecting  more  than  half  an  inch  beyond  edge 
of  ribs  in  right  mammary  line,  and  slightly  tender  on  pressure  ;  in- 
tense jaundice  of  a  deep  olive  tint ;  great  itchiness  of  skin,  and  com- 
plete absence  of  bile  from  motions.  Urine  dark,  like  porter.  Pulse 
60 ;  no  appetite,  nausea  and  flatulence  after  everything  swallowed. 
Patient  was  extremely  weak  and  thin,  and  his  appearance  in  an  older 
man  would  certainly  have  suggested  the  existence  of  malignant  disease 
of  stomach  or  liver. 

The  treatment  adopted  consisted  in  application  of  mustard  and 
linseed  poultices  to  region  of  liver,  warm  baths,  blue  pill  with  saline 
purgatives,  a  mixture  with  citrate  of  potash  and  vinum  colchici,  and  a 
diet  restricted  to  milk,  beef-tea,  and  farinaceous  articles. 

After  two  days  symptoms  began  to  improve,  and  by  end  of  three 
weeks  jaundice  had  quite  disappeared  and  ])atient  was  restored  to  his 
usual  health. 

Case  LXII. — Go%t — Catarrh  of  Bile-ducts — Jaundice. 

Alfred  B ,  38,    leather-cutter,  adm.  into    St.  Thomas's   Hosp. 

Oct.  17,  1874.  Six  years  before  liad  left  facial  paralysis  for  twelve 
months.  Ton  years  before,  eldest  brother  (lour  years  older)  had  gout, 
and  patient  himself  had  been  in  habit  of  drinking  much  beer.  Five 
weeks  before  admission,  wrists,  fingers,  ankles,  and  knees  became 
HwoUeu  and  painful.     After  about  a  week  or  ten  days,  pain  and  swell- 


LECT.  IV.  INFLAMMATION    OF    BILE-DUCTS.  1 57 

ing  subsided,  bat  skin  and  conjunctivae  became  very  yellow,  and  he 
bad  mncb  itchiness  of  skin  and  occasional  vomiting. 

State  on  Admission. — Deep  jaundice.  Liver  slightly  enlarged, 
measuring  5  in.  in  right  nipple  line  ;  lower  edge  smooth  and  painless. 
Tongue  white ;  moderate  appetite ;  much  flatulent  distension  after 
meals  ;  bowels  costive  ;  motions  white  ;  no  vomiting  for  a  fortnight. 
Urine  clear,  but  loaded  with  bile  pigment.  Pulse  108.  Heart  and 
lungs  sound.     Temp.  101°  F. 

Treatment  consisted  of  a  mixture,  three  times  daily,  containing  ci- 
trate of  potash,  iodide  of  potassium,  and  vin.  colchici,  and  compound 
rhubarb  and  blue  pills  on  alternate  nights,  followed  by  a  black  draught 
next  morning,  with  milk  diet.  At  the  end  of  a  week  bile  ap- 
peared in  stools  and  jaundice  began  to  fade.  On  Nov.  12  jaundice  had 
quite  disappeared,  and  two  days  later  patient  left  hospital  well. 

In  the  two  following  cases  catarrli  of  the  bile-ducts  with 
jaundice  appeared  to  result  from  syphilis. 

Case  LXIII. — Consiitutional  Syphilis — Catarrhal  Jaundice. 

Edwin  R ,  aged  25,  adm.  into  Middlesex  Hosp.  Dec.  8,  1868. 

Had  good  health  until  four  months  before,  when  he  contracted 
primary  syphilis,  followed  by  enlargement  of  inguinal  glands  and  a 
roseolar  rash.  Four  weeks  before  admission,  he  began  to  suffer  from 
nausea,  occasional  vomiting,  pain  about  right  shoulder-blade,  a  feelino- 
of  weight  in  head,  dimness  of  sight,  and  general  debility  ;  a  week  later 
he  became  jaundiced,- and  had  diarrhoea  with  much  flatulence. 

On  admission,  great  weakness  ;  jaundice  of  skin  and  conjunctivge, 
and  numerous  copper-coloured  spots  of  psoriasis  upon  skin.  Tono-ue 
white  ;  moderate  appetite ;  pain  in  abdomen  and  eructation  of  gas 
after  food  ;  vomiting  and  diarrhoea  ceased ;  no  bile  in  stools.  Liver 
enlarged,  measuring  6  in.  in  r.  m.  1.  and  extending  2  in.  beyond  ribs  ; 
surface  smooth  and  slightly  tender.  Pulse  84,  regular,  Temp.  100*1°. 
Urine  1020  ;  no  albumen,  but  much  bile-pigment.  Was  ordered 
pil.  coloc.  CO.  with  podophyllin,  sulphate  of  magnesia  and  senna 
draughts,  and  a  mixture  containing  potass,  bitart.  and  sp.  Eeth.  nit. 

Under  this  treatment  the  bowels  and  kidneys  acted  freely,  but  no 
material  improvement  took  place  ;  and  on  Dec.  16  jaundice  not  at  all 
diminished,  urine  loaded  with  bile-pigment,  and  stools  clay-coloured. 
The  patient  was  now  ordered  liq.  hydrarg.  perchlor.  5j  ter  die.  On 
Dec.  21  there  was  decided  evidence  of  bile-pigment  in  urine,  and 
patient  was  ordered  a  warm  bath  and  Dover's  powder  at  bed-time. 
A  few  days  later  the  jaundice  began  to  fade  ;  and  on  Dec.  30  there 
was  only  a  trace  of  bile-pigment  in  the  urine,  the  liver  was  reduced 
in  size,  and  the  jaundice  had  almost  disappeared. 


158  EIS'LAEGEMENTS    OF    THE    LIVER. 


Case  LXI\^. — Catarrh  of  BiU-duds  from  Syphilis  {or  Arsenic  ?) 

Jaundice. 

Josephine  S ,  29,  nurse,  adm.  into  Middlesex  Hosp.  May  30, 

1871.  "Within  three  years  had  passed  through  attacks  of  small-pox, 
relapsing  fever,  and  scarlatina.  A  widow  ;  had  borne  four  children, 
of  whom  one  stillborn  and  another  died  within  a  month  of  birth. 
Denied  syphilis,  but  six  weeks  ago  had  a  sore  throat  which  lasted 
for  some  days.  On  May  19  noticed  an  eruption  on  arms,  neck,  and 
chest,  for  which  on  2Gth  she  consulted  a  doctor,  who  gave  her  a  solu- 
tion of  arsenic,  of  which  she  was  to  take  5  drops  three  times  a  day. 
On  May  27,  after  taking  fourth  dose  of  medicine,  had  great  nausea, 
and  next  day  after  dinner,  and  also  after  medicine,  she  vomited  and 
bowels  acted  four  times.  She  now  discontinued  medicine,  but  on 
29th  she  again  vomited  and  complained  of  pain  and  tenderness  about 
liver,  and  in  the  evening  she  became  jaundiced.  On  morning  of  ad- 
mission had  vomiting  and  slight  purging. 

State  on  admission. — Decided  jaundice.  An  eruption  of  elevated 
copper-coloured,  scaly  spots  over  arms,  back,  front  of  chest,  and  neck. 
Tongue  moist,  with  white  fur  and  red  edges  ;  much  thirst ;  no  appe- 
tite, motions  clay-coloured.  Has  dull  pain  in  right  hypochondrium, 
with  some  tenderness  below  right  ribs  ;  liver  projects  about  an  inch 
beyond  ribs  in  r.  m.  1.  Urine  1025  ;  much  bile-pigment,  but  no  al- 
bumen. Temp.  100-101-5°.  Pulse  112  ;  over  third  left  intercostal 
space  distinct  rougbness  of  first  sound  of  heart. 

Patient  was  ordered  6  grains  of  calomel,  an  occasional  '  black 
draught,'  and  an  effervescing  alkaline  mixture,  and  had  mustard  and 
linseed  poultices  applied  over  right  side,  while  diet  was  restricted  to 
milk,  bread,  and  beef-tea.  On  June  3  the  cutaneous  eruption  had 
increased,  and  patient  complained  of  sore  throat  and  a  deep  ulcer  was 
discovered  on  right  tonsil.  This  was  touched  with  solid  nitrate  of 
silver,  and  mixture  was  changed  for  one  containing  iodide  and  bicar- 
bonate of  potash.  On  June  1  a  little  bile  was  observed  in  stools, 
but  no  material  improvement  took  place  until  June  8,  when  bile  was 
passed  freely  from  the  bowel.  On  June  9  no  trace  of  bile-pigment 
could  be  found  in  urine,  and  after  this  jaundice  rapidly  faded.  On 
July  4  patient  was  discharged  free  from  jaundice,  with  ulcer  of  tonsil 
healed  and  eruption  almost  gone. 

In  the  following  case  deatli  was  due  to  uraemia  from  diseased 
kidneys,  but  the  hepatic  symptoms  appeared  to  result  from  in- 
flammation of  the  gall-bladder  and  bile-ducts  excited  by  gall- 
stones which  was  subsiding  before  death. 


LECr.  IV.  INFLAMMATION    OF    BILE-DUCTS.  1 59 

Case  LXV. — Inflammation  of  Biliary  Passarjes  excited  hy  Gall-stoves — 
Gangrene  of  Foot — Diseased  Kidneys — Death  hy  Unemia. 

Many  of  you  will  remember  the  patient  J.  K ,  aged  49,  who 

was  a  patient  in  Middlesex  Hospital  from  Oct.  27,  1866,  nntil  his  death 
on  Nov.  21.  His  story  was  that  he  had  enjoyed  good  health  until  the 
previous  June,  when  he  began  to  suffer  from  loss  of  appetite,  lowness 
of  spirits,  and  pain  and  flatulence  after  meals.  About  same  time  he 
got  a  rusty  nail  into  his  left  big  toe.  This  resulted  in  an  abscess,  which 
burst  and  continued  discharging  until  a  few  days  before  admission. 
He  had  continued  working,  however,  as  a  labourer  until  within  the 
last  three  weeks.  During  his  illness  his  weight  had  diminished  from 
12  st.  to  11  st.  5  lbs.  On  Oct.  20  he  had  a  severe  rigor,  lasting  for 
three  hours,  and  followed  by  a  rather  severe  constant '  gnawing  '  pain, 
with  tenderness  in  region  of  liver,  vomiting  of  bitter  green  fluid,  and 
headache.  Two  days  later  his  skin  became  jaundiced,  and  he  suffered 
from  itchiness  oE  skin  and  loss  of  sleep.  About  same  time  that  jaun- 
dice appeared,  left  big  toe  became  black,  and  the  ulceration  extended. 
At  no  time  of  his  life  had  he  suffered  from  symptoms  of  biliary  colic. 

On  admission  it  was  noted  that  patient  had  rather  deep  jaundice  of 
skin  and  conjunctivee.  He  complained  of  general  itchiness,  and  of 
dull  pain  in  region  of  liver,  which  was  uniformly  enlarged,  dalness  in 
right  mammary  line  being  5^  in.  There  was  also  decided  tenderness 
at  a  spot  corresponding  to  gall-bladder,  which  was  also  enlarged. 
Abdomen  distended  and  tympanitic  ;  ingesta  were  constantly  vomited 
within  half  an  hour;  tongue  moist,  jaundiced,  and  furred;  bowels 
costive  ;  motions  clay-coloured.  Urine  of  the  colour  of  porter  and 
contained  a  large  quantity  of  bile-pigment,  and  also  of  albumen,  with 
granular  and  a  few  oil-casts.  On  dorsum  and  sole  of  left  bio-  toe  were 
several  large  sloughy  ulcers,  the  surrounding  soft  parts  being  much 
swollen  and  livid.  Pulse  72  ;  skin  cool ;  there  had  been  no  rigors  or 
perspirations.  Patient  was  treated  with  blisters  and  mustard  and 
linseed  poultices  to  region  of  liver,  while  bismuth,  chloric  ether,  pur- 
gatives, &c.,  were  given  internally. 

For  some  time  there  appeared  to  be  considerable  improvement : 
jaundice  diminished,  and  bile  reappeared  in  considerable  quantity  in 
motions.  But  about  Nov.  12  vomiting  became  more  urgent,  and  pros- 
tration increased.  On  Nov.  19  left  foot  was  found  to  be  much  swollen 
and  livid  lines  marking  course  of  lymphatics  passed  up  leo-s.  On 
Nov.  20  an  abscess  was  opened  above  left  ankle,  from  which  fetid  pus 
and  gas  escaped.  On  same  day  the  man  was  seized  with  a  fit  of  con- 
vulsions, followed  by  coma.  These  fits  recurred  in  rapid  succession 
so  that  he  had  nearly  thirty  before  his  death  at  five  p.m.  on  Nov.  21. 

On  examination  of  body  after  death,  brain  audits  membranes  were 
found  to  be  normal,  except  that  there  was  a  considerable  amount  of 
flaid,  which  contained  urea,  at  base  and  in  lateral  ventricles.     Kidneys 


l60  ENLAEGEMENTS   OP   THE    LIVER.  i-ect.  it. 

enlarged,  and  much  fatty  and  granular  deposit  in  secreting  cells.  Liver 
large,  weighing  80  ounces ;  secreting  cells  loaded  with  oil ;  lobules 
unusually  distinct,  giving  a  granular  appearance  to  organ  on  section. 
Gall-bladder  contained  a  soft  black  concretion  as  large  as  a  walnut, 
and  many  small,  irregularly-shaped  fragments  of  same  material.  These 
were  siispended  in  a  small  quantity  of  dark-green  viscid  fluid,  which, 
on  microscopic  examination,  was  found  to  contain  a  large  number  of 
pus-corpuscles.  Mucous  surface  of  gall-bladder  had  a  stretcbed,  white 
appearance,  and  at  fundus  was  deeply  injected,  granular,  and  excori- 
ated. Bile-ducts  contained  a  similar  viscid  fluid  to  that  in  gall-bladder, 
with  minute  particles  of  black  inspissated  bile.  This  could  be  squeezed 
into  duodenum  without  much  difiiculty.  Mucous  membrane  of  stomach 
and  duodenum  minutely  injected,  with  numerous  small  ecchymoses,  and 
surface  coated  with  much  viscid  mucus.  Great  oedema  and  congestion 
of  both  lungs.  Fat  was  deposited  in  large  quantity  throughout  body, 
and  all  the  soft  tissues  were  deeply  jaundiced. 

The  next  form  of  enlargement  of  tlie  liver,  attended  by  pain 
and  jaundice,  to  which  I  wish  to  direct  your  attention,  is — 


VIII.    ENLARGEMENT    FROM    OBSTRUCTION    OF    THE    COMMON 
BILE-DUCT    BY    CALCULI,   TUMOURS,    ETC. 

Obstruction  of  the  common  bile-duct  may  lead  to  enlarge- 
ment of  the  liver  in  two  ways. 

a.  By  causing  dilatation  of  the  biliary  passages  with  ac- 
cumulation of  bile  in  them.  It  is  not  uncommon  to  find  the 
ducts  larger  than  the  middle  finger,  and  many  instances  are 
on  record  where  the  dilatation  has  been  even  greater  than  this. 

1).  By  inducing  inflammation  of  the  biliary  passages  asso- 
ciated with  more  or  less  congestion  and  an  overgrowth  of  the 
connective  tissue.  The  liver  in  these  cases  is  of  a  deep  bilious  or 
olive-o-reen  colour,  and  its  consistence  is  increased.  It  must  not, 
however,  be  forgotten  that,  if  the  obstruction  be  of  long  standing, 
the  liver  may  ultimately  contract  to  less  than  its  natural  size, 
its  secreting  tissue  becoming  atrophied  from  the  pressure  of  the 
distended  bile-ducts  and  of  the  newly  formed  connective  tissue. 
On  microscopic  examination  the  secreting  cells  are  found  to  be 
reduced  in  size  and  very  often  to  contain  an  undue  amount  of 
oil,  and  in  cases  of  long  standing  they  may  be  completely  de- 
stroyed :  while  in  the  capillary  bile-ducts  bile  may  sometimes 
be  seen  crystallised  in  the  form  of  irregular,  ruby-red,  shining 
bodies,  differing  in  form  from  crystals  of  hamatoidin.  The 
primary  enlargement  is  usually  followed  bj'  atrophy  in  about 
three  or  four  months,  but  the  time  varies  in  different  cases. 


LECT.  IV.  OBSTRUCTION   OP    COMMON    DUCT.  l6l 

The  distinguishing  characters  of  the  enlargement  of  the 
liver  that  occurs  under  such  circumstances  are  as  follows  : — 

1.  The  enlargement  is  rarely  great,  and,  with  one  important 
exception,  it  is  uniform  in  every  direction.  The  exception  re- 
ferred to  is  due  to  tlie  enlargement  of  the  gall-bladder,  which 
can  often  be  felt  as  a  pyriform  tumour  projecting  from  the  lower 
margin  of  the  liver.  This  enlargement  is  due,  in  the  first  place, 
to  an  accumulation  of  bile,  but  after  a  time  not  unfrequently  to 
the  admixture  or  substitution  of  inflammatory  products.  The 
late  Dr.  Bright  has  recorded  a  case  in  which  such  an  enlarge- 
ment of  the  gall-bladder  formed  an  oval  tumour  descending 
nearly  to  the  crest  of  the  ilium ;  and  you  have  had  an  oppor- 
tunity of  examining  a  similar,  though  smaller,  tumour  in  the 
case  of  J.  W .     (Case  LXVI.  and  fig  16.) 

2.  There  is  jaundice,  which  if  the  cause  of  obstruction  be 
a  gall-stone,  like  the  pain  about  to  be  referred  to,  is  often  in 
the  first  instance  paroxysmal,  but  by  the  time  that  the  liver 
becomes  enlarged  is  permanent  and  usually  intense,  and  is 
accompanied  by  a  total  disappearance  of  bile-pigment  from  the 
motions.  In  cases  of  persistent  jaundice,  where  from  the 
colour  of  the  motions  it  is  clear  that  the  flow  of  bile  into  the 
bowel  has  been  cut  off  for  many  weeks,  there  can  be  little  doubt 
that  there  is  obstruction  of  the  common  duct;  and  if  the 
jaundice  has  been  preceded  by  paroxysmal  pain,  the  cause  of 
that  obstruction  is  probably  an  impacted  gall-stone.  But  if 
there  be  no  evidence  of  the  jaundice  having  been  preceded  by 
paroxysmal  pain,  it  may  be  difiicult  to  say  whether  the  obstruc- 
tion be  due  to  an  organic  obliteration  of  the  duct  at  its  duodenal 
opening  from  an  ulcer  or  from  a  cancerous  growth  in  the 
duodenum,  or  to  a  tumour  in  some  other  part  of  the  course  of 
the  duct,  or  to  pressure  by  a  tumour  on  the  duct  from  without. 
The  rules  for  your  guidance  under  these  circumstances  will  be 
best  considered  when  I  come  to  describe  the  various  forms 
of  jaundice  arising  from  obstruction  of  the  common  bile- 
duct. 

3.  Pain  and  tenderness  in  the  region  of  the  liver,  and  par- 
ticularly in  the  situation  of  the  enlarged  gall-bladder,  are  pre- 
sent in  most  cases.  The  pain  is  greatest  in  those  cases  where 
there  is  peri-hepatitis,  or  cancer  of  the  liver,  or  where  the  bile- 
duct  is  compressed  by  a  tumour  which  at  the  same  time  com- 
presses and  stretches  the  hepatic  plexus  of  nerves.  When  the 
obstruction  is  due  to  the  impaction  in  the  duct  of  a  gall-stone, 

M 


1 62  ENLARGEMENTS    OF    THE    LIVER.  i.ect.  iv. 

there  will  be  a  history  of  attacks  of  paroxysmal  pain  with  the 
other  phenomena  of  biliary  colic,  but  all  pain  may  have  ceased 
before  the  patient  comes  under  observation. 

4.  The  diagnosis  will  usually  be  assisted  by  the  presence  of 
those  symptoms  which  mark  the  various  morbid  conditions 
producing  obstruction  of  the  bile-duct,  and  which  will  be  con- 
sidered hereafter  under  the  head  of  Jaundice. 

The  treatment  of  this  form  of  enlargement  of  the  liver,  or 
rather  of  its  various  causes,  will  also  be  best  considered  under 
the  head  of  Jaundice. 

In  the  meantime,  I  may  recall  to  your  recollection  the 
following  case,  which  has  been  under  your  observation  for  some 
weeks,  and  which  is  a  good  illustration  of  enlargement  of  the 
liver  and  jaundice,  apparently  from  gall-stones,  except  that  the 
patient's  age  is  considerably  under  that  at  which  gall-stones  are 
ordinarily  met  with.  The  enlargement  of  the  gall-bladder  and 
many  of  the  other  symptoms  appeared  to  be  due  to  catarrhal 
inflammation  of  the  bile -ducts  and  gall-bladder,  excited  by  a 
gall-stone. 


Case  LXVI. — Enlargement  of  Liver  and  Dilatation  of  Gall-bladder 
fram  Ohstruction  of  Common  Bud  by  a  Calculus. 

John  W ,   aged  30,  a  stone-cutter,  adm.  into  Middlesex  Hosp. 

Feb.  5  1807.  He  had  enjoyed  good  health  until  six  months  before, 
-when  he  began  to  suffer  from  acute  paroxysms  of  pain  in  abdomen. 
For  a  week  he  would  have  several  paroxysms  daily ;  then  he  would 
be  free  for  a  week,  and  during  this  interval  he  would  be  able  to  re- 
sume his  work.  The  attacks  were  not  accompanied  by  vomiting,  but 
the  first  was  followed  by  jaundice,  which  had  never  left  him.  Tiie 
paroxysms  continued  to  recur  for  six  weeks,  but  subsequently  to  this 
he  had  none  ;  he  had  suffered  much,  however,  from  flatulence  and 
itchiness  of  skin,  and  had  lost  flesh.  On  admission,  universal  jaundice 
of  moderate  intensity  :  urine  loaded  with  bile-pigment,  but  motions 
contained  none.  Hepatic  dulness  moderately  and  uniformly  increased, 
measuring  five  inches  in  right  mammary  line.  No  tumour  corre- 
sponding to  gall-bladder  could  be  discovered,  but  possibly  this  was  ob- 
scured by  the  flatulent  distension  of  bowels ;  no  ascites.  Tongue 
moist,  and  but  slightly  furred  ;  appetite  good,  and  no  vomiting ;  but 
patient  was  obliged  to  be  very  careful  as  to  diet,  as  he  suffered  much 
from  flatulence  and  pain  after  eating  ;  pulse  72. 

About  a  fortnight  after  patient's  admission  he  became  much  worse  ; 
and  on  Feb.  20  it  was  noted   that  jaundice   was  more  intense,   urine 


OBSTRUCTION    OF    COMMON    DUCT. 


i6- 


darker,  and  hepatic  dulness  increased,  measuring  fully  5^  in.  in 
right  mammary  line.  In  addition,  there  was  now  in  situation  of 
gall-bladder  a  distinct  tumour  (see  fig.  16),  extending  1^  in.  behjw 
margin  of  liver,  measuring  2^  in.  transversely,  and  tender  on  pres- 
sure. Temperature  had  risen  to  104'2''  F.,  and  pulse  to  96.  Tongue 
somewhat  dry,  motions  perfectly  devoid  of  bile.  These  symptoms 
continued,  with  occasional  vomiting,  for  several  days  ;  but  on  Feb.  25 


Fig.  16. 


Shows  the  Enlargement  of  Liver  and  Tnmour  in  case  of  J.  W.,  on  Feb.  20. 
Compare  this  with  Fig.  3,  at  p.  4. 


temperature  had  fallen  to  99-2°,  and  on  27th  to  97°.  On  March  1 
pulse  "was  down  to  72,  and  tumour  in  region  of  gall-bladder  had  dis- 
appeared. On  March  4  motions  contained  much  bile,  and  jaundice 
was  fading.  By  beginning  of  April  jaundice  had  almost  disappeared, 
and  in  May  patient  was  able  to  resume  his  employment. 

The  motions  were  carefully  searched  for  gall-stones  for  ten  days 
subsequent  to  Feb.  24,  but  none  were  found.  Possibly  a  gall-stone 
may  have  either  become  disintegrated,  or  slipped  back  into  gall-bladder. 
During  acute  stage  the  patient  was  treated  with  alkalies,  ammonia, 
ether,  belladonna,  and  opium.  During  convalescence,  strychnia  ap- 
peared to  relieve  flatulence,  and  disappearance  of  jaundice  was  en- 
couraged by  warm  baths  and  diaphoretics. 


K  2 


164  ENLARGEMENTS    OF   THE    LIVEE. 


LECTURE   Y. 
ENLARGEMENTS   OF  THE  LIVER. 

SUPPURATIVE    INFLAMMATION — PYEMIC  ABSCESSES — TROPICAL 

ABSCESS. 

Gentlemen, — The  first  form  of  enlargement  of  the  liver  to 
which  I  desire  to  draw  your  attention  to-day  is  that  due  to 

IX.    PYEMIC    ABSCESSES. 

The  abscesses  which  are  often  developed  in  the  liver  in  the 
course  of  pysemia  are  for  the  most  part  many  in  number  and 
small  in  size,  and  in  these  respects  they  differ  from  the  tropical 
abscess,  which  is  usually  single  and  often  attains  a  large  size, 
so  as  to  form  a  distinct  tumour.  The  clinical  characters  vary 
in  accordance  with  this  anatomical  difference,  and  with  the 
different  conditions  under  which  the  hepatic  disease  occurs. 
Those  of  the  pysemic  abscess  are  as  follows : — 

1.  There  is  enlargement  of  the  liver,  usually  of  moderate 
extent  but  sometimes  so  great  that  the  lower  margin  of  the 
organ  reaches  to  the  umbilicus. 

2.  The  enlargement  is  uniform  in  every  direction,  and  does 
not  produce  any  bulging  of  the  ribs.  In  exceptional  cases  only 
one  of  the  abscesses  enlarges  somewhat  more  than  the  others 
and  forms  a  small  bulging  tumour  at  the  epigastrium ;  and  in 
cases  of  still  rarer  occurrence,  the  lower  margin  of  the  liver,  as 
felt  through  the  abdominal  parietes,  has  a  nodulated  character 
from  the  presence  of  several  small  abscesses  or  inflammatory 
deposits  along  its  free  margin. 

3.  No  fluctuation  can  be  felt  in  the  enlarged  liver.  The 
abscesses  are  rarely  large  enough  to  admit  of  this.  Only  in 
those  rare  cases  where  one  of  the  abscesses  enlarges  so  as  to  form 
a  bulging'  in  the  epigastrium,  or  where  a  small  quantity  of  pus 


J.ECT.  V.  PYEMIC    ABSCESSES.  1 65 

becomes  encysted  between  the  liver  and  abdominal  wall  (Case 
LXX.),  is  anything  approaching  to  fluctuation  perceptible. 

4.  Pain  and  tenderness  are  always  present.  They  are  often 
among  the  first  symptoms  noted,  and  are  usually  acute  in  con- 
sequence of  some  of  the  abscesses  being  near  the  surface  of  the 
liver,  and  of  the  inflammatory  action  being  propagated  from 
them  to  the  superimposed  peritoneum.  The  pain  is  often 
increased  by  coughing  or  by  along  inspiration,  so  that  in  conse- 
quence the  respirations  are  quick  and  short,  and  mainly  thoracic. 

5.  Jaundice  is  present  in  the  majority  of  cases — in  fully 
four-fifths ;  but  the  possibility  of  its  absence  must  be  kept  in 
view  in  diagnosis.  The  intensity  of  the  jaundice  varies.  In 
most  cases  it  is  due  to  the  morbid  condition  of  the  blood  to 
which  the  term  pysemia  is  applied,  just  as  jaundice  is  known  to 
result  from  other  blood-poisons,  and  then  it  is  usually  slight, 
and  the  motions  are  still  tinged  with  bile-pigment ;  but  if  the 
inflammation  be  due  to  an  ulcer  of  the  biliary  passages,  excited 
by  the  pressure  of  an  impacted  gall-stone,  the  jaundice  may  be 
intense  and  the  excrement  devoid  of  bile-pigment. 

6.  Pyaamic  abscesses  of  the  liver  rarely  interfere  with  the 
portal  circulation.  Accordingly  there  is  no  enlargement  of  the 
veins  of  the  abdominal  parietes,  and  only  in  exceptional  cases 
(from  implication  of  a  large  branch  of  the  vein),  ascites.  Occa- 
sionally fluid  is  thrown  out  into  the  peritoneum  as  the  result 
of  peritonitis.  The  spleen  is  usually  enlarged,  owing,  not  to 
obstructed  circulation,  but  to  the  tendency  of  that  organ  to 
enlarge  in  consequence  of  the  morbid  condition  of  the  blood,  as 
happens  in  most  diseases  originating  in  a  blood-poison. 

7.  The  constitutional  symptoms  are  important  in  diagnosis. 
They  are  mainly  those  of  fever,  at  first  hectic  and  ultimately 
typhoid  in  its  type.  Rigors  afford  material  assistance  in  dia- 
gnosis ;  but  it  is  well  to  remember  that  they  are  not  a  necessary 
symptom.  The  rigors  at  first  occasionally  recur  at  such  regular 
intervals  that  the  attack  simulates  ague ;  errors  in  diagnosis 
are  constantly  committed  from  this  fact  not  being  remembered 
(Case  LXYIII).  On  the  other  hand,  the  possibility  of  rigors 
and  even  pyrexia,  resulting  from  the  passage  of  a  gall-stone, 
without  any  secondary  inflammation  of  the  liver,  must  not  be 
lost  sight  of.  The  temperature  exhibits  great  oscillations  ; 
sometimes  it  is  normal,  at  others  it  reaches  104°  or  106° ;  m 
rare  cases  there  appears  to  be  no  elevation  of  temperature, 
perhaps  from  the  fever  paroxysms  being  so  short  as  to  escape 


1 66  ENLARGEMENTS    OF   THE    LIVER.  lect.  v. 

detection  (Case  LXXII.).  Profuse  perspirations  during  sleep 
are  less  frequently  absent  than  rigors.  Day  by  day  the  patient 
becomes  more  emaciated  and  prostrate,  and  not  unfrequently 
there  is  vomiting  and  attacks  of  diarrhoea.  As  the  disease 
advances,  typhoid  symptoms  such  as  a  dry  brown  tongue,  rest- 
lessness, delirium,  involuntary  evacuations,  &c.,  make  their 
appearance. 

8.  The  course  of  the  disease  is  rapid,  usually  ranging  from 
two  or  three  weeks  to  three  months.  I  have  never  known  the 
latter  limit  exceeded,  although  Leudet  mentions  a  case  which 
lasted  as  long  as  five  months.'  This  rapid  course  may  be  of 
service  in  diagnosing  cancer,  in  which  the  duration  is  usually 
more  protracted,  from  pysemic  abscesses  of  the  liver. 

9.  The  diagnosis  will  also  be  assisted  by  keeping  in  view 
the  circumstances  under  which  the  disease  usually  occurs. 
Among  them  the  following  hold  a  prominent  place  : — 

a.  External  injuries  and  surgical  operations.  When  sym- 
ptoms like  those  above  described  follow  either  of  the  causes  now 
mentioned,  there  need  be  no  difficulty  about  the  diagnosis.  The 
most  of  the  cases,  however,  which  come  under  the  care  of  the 
physician  depend  upon  internal  causes,  and  then  the  difficulty 
is  increased. 

h.  Ulceration  of  the  stomach  or  intestine.  I  have  in  several 
instances  known  pyijemic  abscess  of  the  liver  supervene  upon 
simple  ulcer  of  the  stomach,  and  I  shall  relate  to  you  imme- 
diately the  particulars  of  a  case  where  this  occurred.  It  may  also 
follow  ulceration  of  any  portion  of  the  intestine,  such  as  an 
ulcer  of  the  appendix  vermiformis,  or  dysenteric  ulceration  of 
the  colon,  or  even  cancerous  ulceration  of  the  stomach  or  bowel. 
Pysemic  deposits  in  the  liver,  however,  only  occur  in  exceptional 
cases  of  intes^tinal  ulceration,  probably  for  the  same  reason  that 
general  pyajmia  only  occurs  in  exceptional  cases  of  external 
injury  (see  p.  178). 

c.  Ulceration  of  the  gall-bladder  or  of  the  bile-ducts  may 
give  rise  to  pyemic  abscesses  of  the  liver,  which  in  this  way 
may  be  a  sequel  of  gall-stones.  I  shall  narrate  to  you  presently 
cases  where  an  ordinary  attack  of  biliary  colic  came  in  this  way 
to  be  followed  by  fatal  inflammation  of  the  liver  (Case  LXXI.). 
It  may  be  added  that  when  the  common  bile-duct  is  obstructed 
by  a  gall-stone  or  from  any  other  cause,  the  ducts  in  the  interior 

'  Clin.  M6d.,  Paris,  1874,  p.  33. 


LECT.  V.  PYEMIC    ABSCESSES.  1 6/ 

of  the  liver  may  become  dilated  into  irregular  cavities  full  of  pus,^ 
or  may  rupture  and  form  small  abscesses,  and  in  either  case 
there  may  result  many  of  the  symptoms  of  pysemic  hepatitis.^ 

d.  In  a  former  lecture  I  brought  before  your  notice  instances 
in  which  a  suppurating  hydatid  cyst  appeared  to  be  the  starting 
point  of  pysemic  abscesses  in  the  liver  (see  pp.   1 14  and  1 19). 

e.  Lastly,  any  suppurating  ulcer  or  cavity  on  or  near  the 
outer  surface  or  in  the  interior  of  the  body,  especially  if  in  con- 
nection v^^ith  diseased  bone  or  communicating  with  the  external 
atmosphere,  may  induce  pyaemia  with  secondary  deposits  in  the 
liver.  On  more  than  one  occasion,  for  instance,  I  have  found 
these  deposits  in  the  liver  resulting  from  a  tubercular  vomica 
in  the  lungs,  ulcerative  endocarditis,  calculous  pyelitis,  &c. 

When  the  signs  and  symptoms  already  enumerated  super- 
vene on  those  of  any  of  the  maladies  now  referred  to,  the  pro- 
bability of  pysemic  abscesses  of  the  liver  ought  at  once  to  suggest 
itself.  But  occasionally  the  primary  disease  is  latent,  and  the 
first  symptoms  are  those  of  inflammation  of  the  liver.  Even 
then,  however,  the  probability  of  pysemic  abscesses  ought  to 
suggest  itself  in  English  practice,  inasmuch  as,  with  extremely 
rare  exceptions,  this  is  the  only  form  of  hepatic  abscess  met 
■with,  in  this  country  in  persons  who  have  never  been  in  a  tropi- 
cal climate. 

Treatment. — In  pysemic  abscesses  of  the  liver,  medical  art,  it 
is  to  be  feared,  is  powerless  to  avert  the  fatal  result,  and  can 
only  mitigate  the  patient's  suffering. 

1.  By  hygienic  arrangements,  by  the  antiseptic  treatment  of 
open  sores  and  wounds,  and  by  evacuating  decomposing  pus 
pent  up  in  any  part  of  the  body,  much  can  be  done  in  the  way  of 
preventing  general  pyaemia  in  surgical  injuries  ;  but  unfortunately 
in  a  large  number  of  cases  of  pysemic  abscesses  in  the  liver  that 
come  under  the  physician,  the  primary  disease  is  inaccessible. 

2.  Depletion,  both  general  and  local,  is  contraindicated ; 
but  if  the  pain  be  very  acute  it  will  often  be  materially  relieved 
by  the  application  of  a  few  leeches  to  the  region  of  the  liver. 


'  Dr.  Legg  has  recorded  an  interesting  case  where  in  consequence  of  a  gall-stone 
in  the  common  duct,  all  the  bile  ducts  became  greatly  dilated,  and  an  abscess  formed 
in  the  left  lobe  of  the  liver,  which  found  its  way  into  the  pericardium  and  right 
pleura.     Path.  Trans,  xxv.  133. 

2  It  is  even  said  that  dilatation  of  the  ducts  into  suppurating  cavities  may  result 
from  disease  of  their  walls,  independently  of  obstruction.  See  Dr.  Grainger  Stewart, 
Edin.  Med.  Journ.,  Jan,  1873,  p.  631, 


1 68  ENLARGEMENTS    OF    THE    LIVER.  lect.  v. 

Mustard  and  linseed  poultices  are  also  useful  for  relieving  the 
pain. 

8.  Since  the  discovery  of  bacteria  in  the  blood  of  pyaemia 
much  has  been  written  about  the  internal  administration  of 
antiseptics,  but  proofs  are  still  wanting  of  their  utility.  Pro- 
fessor Polli,  of  Milan,  has  strongly  recommended  the  sulphites 
of  potash  and  soda  as  antidotes  for  the  pysemic  poison.  The 
power  which  these  substances  possess  of  arresting  putrefaction 
or  fermentation  out  of  the  body  it  is  believed  that  they  can 
exercise  in  the  living  blood.  I  have  tried  them  repeatedly, 
and  I  regret  to  say  that  in  my  practice,  in  doses  of  twenty  or 
thirty  grains  every  four  hours,  they  have  signally  failed.  The 
sulphocarbolates  of  lime  and  soda,  and  the  subcutaneous  in- 
jt^ction  of  carbolic  acid  have  also  been  tried,  but  without  any 
permanently  good  result. 

4.  Quinine  and  mineral  acids  have  appeared  to  me  to  be 
the  remedies  most  generally  useful.  They  support  the  patient's 
strength,  keep  the  tongue  moist,  postpone  the  paroxysms  of 
pyrexia,  and  tend  to  diminish  the  profuse  sweating. 

5.  The  hydrate  of  chloral,  opium,  or  morphia  will  be  neces- 
sary in  most  cases  to  relieve  pain  or  procure  sleep.  If  there  be 
much  retching,  the  subcutaneous  injection  of  morphia  will  be 
jDreferable  to  administering  oj^iates  by  the  mouth. 

6.  The  treatment  must  often  be  modified  in  such  a  way  as 
to  counteract  various  distressing  symptoms  which  are  apt  to 
arise,  and  more  especially  vomiting  and  diarrhoea.  For  the 
vomiting,  the  best  remedies  are  ice,  bismuth,  hydrocyanic  acid, 
effervescing  alkaline  draughts,  and  the  application  to  the 
epigastrium  of  sinapisms  or  of  a  small  blister,  followed  by  the 
sprinkling  of  a  quarter  of  a  grain  of  morphia  on  the  blistered 
surface.  For  the  diarrhoea  you  must  have  recourse  to  vegetable 
and  mineral  astringents,  and  particularly  the  acetate  of  lead 
and  mc»rphia,  and  to  opiate  enemata  and  suppositories. 

7.  The  diet  must  be  of  as  nutritious  a  character  as  is  com- 
patible with  the  patient's  digestive  powers.  It  ought  to  consist 
of  such  articles  as  milk,  beef  tea,  and  eggs,  given  frequently, 
but  in  small  quantities  at  a  time.  In  most  cases  it  will  be 
necessary  to  give  small  quantities  of  wine  or  brandy,  which 
ought  to  be  well  diluted. 

I  shall  now  proceed  to  relate  to  you  the  particulars  of  a  few 
cases  in  illustration  of  the  foregoing  remarks.  In  the  first 
case  the  hepatic  disease  was  the  result  of  an  external  injury. 


LECT.  V.  PYEMIC    ABSCESSES.  1 69 

Case  LXVII. — Injury  of  Cranmm,  followed  hij  Pycemia  and  MuUijjle 
Abscesses  in  Liver. 

Thomas  D ,  aged  21,  was  admitted  into  one  of  surgical  wards 

of  Middlesex  Hosp.  Aug  16,  1867,  with  lacerated  wonnds  of  scalp, 
fracture  of  sixth  left  rib,  and  bruise  of  left  shoulder— injuries  which 
he  had  received  from  being  run  over  by  a  cab.  He  had  so  far  re- 
covered that  on  Sept.  3  he  was  able  to  be  out  in  garden ;  but  on  same 
day  he  was  seized  with  rigors,  followed  by  febrile  symptoms,  headache, 
and  loss  of  appetite.  During  next  two  days  he  had  several  attacks  of 
severe  rigors,  like  those  of  ague,  fallowed  by  moderate  perspiration 
and  frequent  vomiting. 

When  he  first  came  under  my  care,  on  Sept.  6,  he  had  all  the 
.symptoms  of  blood-poisoning,  but  without  any  eruption  on  skin.  Pulse 
120 ;  resp.  36  ;  temp.  103°.  Alternate  fits  of  chilliness  and  perspira- 
tion. Countenance  heavy  and  depressed  ;  great  lassitude  ;  throbbing 
headache,  but  mind  quite  clear  ;  great  prostration,  and  tendency  to 
syncope  on  sitting  up  ;  frequent  retching,  with  tenderness  in  epigastrium 
and  right  hypochondrium.  Tongue  moist,  and  but  slightly  furred. 
Bowels  had  been  freely  opened  by  medicine.  Cardiac  and  respiratory 
signs  normal.  Urine  contained  a  small  quantity  of  albumen,  with 
blood-corpuscles  and  epithelial  casts.  A  wound  in  left  temporal  region 
was  covered  with  a  hard  scab,  from  beneath  which  about  a  teaspoonful 
of  dirty,  not  fetid,  pus  could  be  squeezed.  Soon  after  patient's  admis- 
sion he  became  very  restless  and  delii'ious  ;  there  was  no  paralysis,  but 
hearing  was  preternaturally  acute.  Tongue  became  dry  and  brown, 
and  there  was  frequent  vomiting  with  a  tendency  to  diarrhoea.  Ten- 
derness in  epigastrium  and  right  hypochondrium  continued,  and  hepa- 
tic dulness  became  much  increased,  extending  down  almost  to  umbi- 
licus ;  surface  smooth.     Skin  sallow,  but  no  decided  jaundice. 

Patient  was  treated  mainly  according  to  plan  recommended  for 
pyaemia  by  Professor  Polli,  of  Milan,  with  large  doses  of  sulphites. 
Sulphite  of  soda  was  given  in  doses  of  fifteen  grains  every  four  hours. 
No  improvement,  however,  was  observed ;  and  the  symptoms  above 
noted  continued  almost  till  death,  at  9.45  p.m.  on  Sept.  9. 

On  examination  of  body  about  a  square  inch  of  bone,  correspond- 
ing to  wound  in  scalp,  was  bare  and  discoloured.  The  bone  ap- 
peared scratched  on  surface.  It  was  not  fractured ;  but  between  its 
under  surface  and  corresponding  dura-mater  there  was  about  a  drachm 
of  pus  ;  veins  leading  from  this  to  longitudinal  sinus  contained  pale, 
soft,  non-adherent  coagula.  Liver  very  large,  extending  down  to 
umbilicus,  and  weighing  104  oz.  Its  tissue  was  dark  and  in- 
tensely injected,  and  riddled  with  innumerable  pyaemic  deposits 
breaking  down  into  pus,  from  size  of  a  pin's-head  up  to  that  of  a 
walnut.  Spleen  large,  weighed  10^  oz.,  and  was  dark  and  firm, 
but  contained  no  infarctions.     Both  kidneys  much  enlai'ged,  weighing 


I/O  ENLAEGEMENTS    OF    THE    LIVER.  lect.  v. 

together  18 j  ounces  ;  surfaces  smooth,  and  capsules  non-adherent ; 
cortical  substance  greatly  hypertrophied  and  deeply  injected,  but  free 
from  pyaemic  deposits.  Sixth  left  rib  was  fractured  at  about  two 
inches  from  cartilage  ;  edges  overlapped,  and  were  enveloped  in  callus  ; 
but  there  was  no  trace  of  laceration  of  lung,  or  of  pleurisy — old 
or  recent — in  neighbourhood.  Slight  traces  of  recent  pericarditis,  and 
numerous  minute  ecchymoses  beneath  pericardium. 

In   the   second  case  the  hepatic  inflammation  followed  a 
simple  ulcer  of  the  stomach. 

Case  LXVIII. — Multiple  Abscesses  in  Liver  secondary  to  simple 
Ulcer  of  StomachA 

John  P ,  aged  51,  was  admitted  into  London  Fever  Hosp.  on 

Oct,  6, 1865.  For  six  weeks  he  had  been  suffering  from  pain,  tender- 
ness, and  flatulence  in  abdomen  after  food,  followed  occasionally  by 
vomiting.  He  had  suffered  from  similar  symptoms  on  former 
occasions,  but  had  always  recovered.  Hepatic  dulne.ss  4-^  in.  in 
right  mammary  line  ;  no  jaundice.  Pulse  84.  Bismuth  and  a  milk 
diet  were  prescribed.  Three  days  after  admission  it  was  noticed  that 
patient  had  a  daily  febrile  accession  about  one  p.m.  ;  and  it  was  ascer- 
tained that  twenty-two  years  before  (but  never  since  then)  he  had 
suffered  from  ague  in  Kent.  Quinine  was  accordingly  administered 
in  large  doses.  It  had  no  effect,  however,  on  paroxysms.  On  the 
contrary,  they  became  more  severe,  came  on  at  irregular  intervals, 
and  were  followed  by  profuse  perspirations  and  great  prostration. 
Tongue  also  became  dry  and  brown,  pain  and  tenderness  at  epigas- 
trium were  greatly  increased,  and  bowels  were  very  loose.  On  Oct. 
16  it  was  noted  that  he  was  much  lower  and  greatly  emaciated,  and 
that  skin  and  conjunctivae  had  a  decidedly  jaundiced  tint,  although 
motions  contained  plenty  of  bile.  Hepatic  dulness  in  right  mammary 
line  was  now  5^  in.,  but  enlargement  was  uniform,  and  free  from 
nodulation  ;  considerable  tenderness  on  pressure  below  lower  margin 
of  right  ribs.  Splenic  dulness  increased.  Pulse  96  ;  temp.  101°. 
The  symptoms  above  narrated  became  gradually  aggravated.  He  still 
had  irregular  paroxysms  of  rigors,  followed  Ijy  fever  and  sweating. 
On  Oct.  21  jaundice  was  noted  as  deep,  although  bile  was  still  present 
in  motions  ;  mind  was  slightly  confused,  and  he  had  occasional  low 
delirium.     He  gradually  sank,  and  died  on  Oct.  24. 

On  post-mortem  examination,  near  pyloric  end  of  stomach,  on  its 
lower  and  posterior  surface,  was  a  circular  ulcer  size  of  a  crown-piece, 
with  its  edges  slightly  elevated  and  indurated,  but  containing  none  of 
microscopic  elements  of  cancer.     From  base  of  this  ulcer  a  small  fis- 

'  A  second  case  of  a  bimilar  nature  is  recorded  Ly  nie  iii  the  Path.  Trans,  vol.  xvii. 
p.  146. 


tECT.  V.  PYEMIC   ABSCESSES.  •  I/I 

tulous  channel  passed  into  an  abscess  almost  the  size  of  a  "walnnt  in 
head  of  pancreas.  Liver  generally  enlarged,  and  weighed  81  oz.  ; 
posterior  half  of  right  lobe  studded  with  minute  abscesses,  from 
size  of  a  pin's-head  up  to  that  of  a  pea,  containing  thick  yellow  pus  ; 
intervening  hepatic  tissue  very  hypereemic  ;  no  peritoneal  inflammation 
over  surface  of  liver.  Spleen  large,  dark,  and  firm.  Other  organs 
healthy. 

In  Case  LXIX.  pysemic  hepatitis  followed  ulceration  of  tlie 
appendix  vermiformis. 

Case  LXIX. — Ulceration  of  Appendix  Vermiformis — Pycemic  Hepatitis. 

Richard  S ,  aged  15,  adm.  into  Middlesex  Hosp.  Oct.  19,  1869. 

Had  been  in  the  hospital  from  April  30  to  May  25  under  Dr.  Good- 
fellow,  for  some  obscure  febrile  attack  with  pain  and  tenderness  in  right 
loin.  Between  1  and  2  a.m.  of  Sept.  29  had  been  seized  suddenly  with 
bilious  vomiting,  acute  paia  in  right  side  of  abdomen,  and  pyrexia. 
Vomiting  had  subsided  after  36  hours,  but  other  symptoms  persisted 
until  Oct.  10,  when  he  had  severe  rigors  lasting  quarter  of  an  hour. 
From  this  date  he  daily  became  worse,  and  on  Oct.  17  and  18  there 
were  recurrences  of  rigors. 

On  admission,  emaciated  ;  features  pinched  and  expressive  of  pain  ; 
frequent  moaning  from  pain  referred  to  right  side  of  abdomen,  which 
was  very  tender,  especially  over  caecum  ;  no  appreciable  tumour  and 
abdomen  not  at  all  distended,  but  respiration  mainly  thoracic.  Tongue 
white,  but  at  tip  red  and  dry  ;  bowels  not  acted  for  a  week.  Pulse  96  ; 
temp.  98°,  but  next  morning  101°.  Signs  of  heart  and  lungs  normal. 
Urine  free  from  albumen.  The  treatment  consisted  in  a  simple  enema, 
laudanum  poultices  to  abdomen,  and  a  grain  of  opium,  at  first  every 
four,  and  afterwards  every  eight,  hours.  Enema  acted  freely  but  gave 
no  relief  to  pain,  which  abated  under  use  of  opium.  Xo  improvement, 
however,  took  place  in  patient's  general  condition.  Some  days  he  was 
better,  and  some  days  worse.  On  Nov.  5  liver  was  noted  as  enlarged 
and  tender,  measured  6  in.  in  r.  m.  1.  ;  and  throughout  temperature 
was  liable  to  great  and  sudden  variations  (99°  to  105"3°)  but  there 
were  no  rigors,  jaundice,  albuminuria,  or  profuse  general  perspirations, 
although  face  was  covered  with  large  drops  of  moisture  during  sleep. 
Tongue  mostly  dry,  red,  and  preternaturally  clean  ;  bowels  confined  ; 
after  the  first  relief,  notwithstanding  several  ene'mata,  they  did  not  act 
for  ten  days.  On  Xov.  10  signs  of  consolidation  of  lower  third  of 
right  lung  were  discovered.  About  Nov.  15  abdomen  began  to  in- 
crease in  size,  and  on  24th  there  was  distinct  evidence  of  fluid  in  peri- 
toneum, but  still  no  rigors,  jaundice,  or  return  of  vomiting.  On  Xov. 
29,  pain,  which  had  abated,  became  very  intense,  and  was  referred  more 
to  left  side  of  abdomen.  After  this,  appetite  failed,  prostration  in- 
creased, temperature  fell,  and  was  often  subnormal    (on  Dec.  3  only 


172  ENLARGEMENTS    OF    THE    LIVER.  iect.  v. 

9o-2°),  and  pulse  was  from  84-  to  92.     A  bedsore  formed  over  sacrum, 
and  patient  gradually  sank  and  died  on  Dec.  11. 

A^iUipstj. — Extreme  emaciation.  Two  pints  of  flaky  fluid  in  perito- 
neum. Intestines  deeply  injected  and  coated  with  recent  lymph,  most 
abundant  over  caecum  and  ascending  colon.  Mucous  membrane  of 
caecum  and  colon  free  from  ulceration  or  cicatrix.  Appendix  venni- 
formis  unusually  long,  its  upper  two  inches  pervious  and  healthy,  but 
the  distal  half  thickened,  indurated,  impervious,  and  adherent  to  cajcum. 
No  foreign  body  or  concretion  found.  Both  lobes  of  liver  studded  with 
numerous  small  circumscribed  abscesses,  several  of  them  in  back  part 
of  right  lobe  merging  into  one.  Glands  in  fissure  of  liver  enlarged 
and  suppurating.  Gall-bladder  distended  with  about  two  fluid  ounces  of 
thin  mucous  fluid  ;  no  calculus,  abrasion,  or  redness  of  lining  mem- 
brane of  gall-bladder  or  of  ducts.  No  ulceration  of  stomach,  or  of 
intestine.  Granular  consolidation  of  lower  lobe  of  right  lung.  Other 
organs  healthy. 

In  the  next  case  a  cancerous  ulcer  of  the  stomach  appeared 
to  be  the  exciting  cause  of  the  disease  in  the  liver.  The  case 
has  additional  interest  from  the  fact  that  there  was  a  small 
fluctuating  tumour  at  the  epigastrium,  caused  by  a  circum- 
scribed collection  of  pus  between  the  liver  and  abdominal 
parietes. 

Case  LXX. — Cancerous  Ulcers  of  Stoviach  followed  hy  Pycemic  Abscesses 

of  the  Liver. 

In  June  18G7  I  was  requested  by  Dr.  Rogers,  of  Dean  Street,  to 
see  a  patient  under  his  care.  He  was  a  man,  aged  45,  whose  father 
and  sister  were  said  to  have  died  of  cancer.  For  several  months  he 
had  been  losing  flesh,  and  had  suffered  pain  after  food,  and  other  sym- 
ptoms of  indigestion,  but  not  vomiting.  About  May  19  his  symptoms 
became  worse,  and  he  first  consulted  Dr.  Rogers.  He  then  began  to 
suffer  from  a  constant  pain  in  right  side,  febrile  symptoms,  dyspnoea, 
and  a  frequent  dry  cough,  and  on  May  23  and  again  on  the  28th  he 
had  severe  attacks  of  vomiting.  About  June  2  a  slight  swelling  was 
first  noticed  iu  epigastrium,  and  he  became  slightly  jaundiced,  and 
when  I  sa\y  him  on  June  8  with  Drs.  Anstie  and  Rogers,  there  was 
considerable  jaundice,  with  great  emaciation  and  prostration.  Pulse 
quick  and  feeble,  and  a  tendency  to  nocturnal  perspiration,  but  no 
rigors.  Tongue  moist,  clean,  and  red  ;  no  vomiting  or  diarrhoea,  and 
motions  contained  bile.  Liver  much  enlarged,  and  in  epigastrium  there 
was  a  very  painful  prominent  tumour,  about  size  of  half  an  orange, 
extremely  elastic,  and  indeed  apparently  fluctuating.  An  exploratory 
puncture  was  made  into  this  tumour,  but  only  a  few  drops  of  blood 
came  away.      Patient  becamo  daily  more  emaciated  and  prostrate  ; 


LECT.  V.  PYEMIC    ABSCESSES.  1 73 

tongue  became  dry  and  brown,  and  jaundice  increased  although  stools 
still  contained  bile-pigment.  On  June  24  he  died  from  exhaustion. 
Throughout  there  had  been  no  rigors,  and  only  slight  perspiration 
during  sleep. 

On  examining  body,  liver  was  found  of  almost  twice  normal  size  ; 
signs  of  recent  peritonitis  over  its  outer  surface  ;  glandular  tissue  was 
extremely  congested,  and  was  studded  with  inflammatory  (not  can- 
cerous) deposits  up  to  size  of  a  walnut,  which  were  pale  yellow,  granular, 
and  very  friable,  but  which  had  not  yet  softened  into  pus.  Between 
left  lobe  and  abdominal  wall  there  was  about  an  ounce  of  pus  circum- 
scribed by  firm  adhesions.  This  accounted  for  fluctuating  tumour  felt 
during  life  ;  the  fine  trocar  had  probably  passed  through  the  abscess 
into  liver,  and  thus  no  pus  had  been  obtained  by  the  puncture.  On 
opening  stomach  an  ulcer  was  found  about  2  in.  from  the  pylorus  ; 
edges  and  base  of  this  ulcer  were  indurated  from  what  microscope 
showed  to  be  cancerous  tissue,  and  surface  of  the  ulcer  was  ragged 
and  sloughy. 

The  next  case  whicli  I  shall  refer  to  is  that  of  a  ladj  23 
years  of  age,  whom  I  saw  in  consultation  with  the  late  Mr. 
Young,  of  Sackville  Street,  in  November  and  December  1861. 
It  affords  an  illustration  of  pyeemic  abscesses  of  the  liver 
supervening  on  gall-stones. 

Case  LXXI. — Attacks  of  Biliary  Colic  followed  by  Pyeemic  Abscesses  in 

Liver. 

On  November  30,  1861,  I  was  called  to  see  Mrs. ,  aged  23,  who 

had  been  married  only  four  or  five  months.  Two  years  before  she  had 
suffered  for  several  weeks  from  jaundice,  with  severe  attacks  of  biliary 
colic.  Ten  days  before  I  saw  her  the  jaundice  had  returned,  and  dur- 
ing same  period  she  had  been  suffering  from  severe  paroxysms  of  pain, 
in  right  hypochondrium,  often  accompanied  by  vomiting.  Although, 
notwithstanding  patient's  age,  her  history  was  clearly  one  of  gall-stones, 
yet,  after  making  allowance  for  her  hysterical  temperament,  the 
symptoms  led  to  the  suspicion  that  there  was  something  more.  The  pulse 
was  100,  and  there  was  an  unusual  amount  of  tenderness  in  region  of 
liver,  and  particularly  in  situation  of  gall-bladder.  Hepatic  dulness 
was  increased  ;  there  was  also  great  increase  of  splenic  dulness.  The 
jaundice  was  of  moderate  intensity ;  and  motions,  thoug-h  very  pale, 
were  not  entirely  devoid  of  bile-pigment.  Leeches,  followed  by  warm 
fomentations,  were  appliedto  right  hypochondrium,  and  repeated  doses 
of  opium  were  prescribed. 

During  first  week  in  December  patient  had  frequent  attacks  of 
vomiting,  and  on  4th  she  miscarried  at  third  month.  After  this  she 
became  much  worse.     She  had  repeated  attacks  of  rigors,  lasting  for 


174  ENLARGEMENTS   OF    THE    LIVER.  lect.  v. 

half  an  hour  or  more,  and  often  followed  by  involuntary  discharge  of 
light-yellow  fluid  from  bowels.  She  had  also  frequent  and  severe 
paroxysms  of  retching,  and  the  pain  in  right  side  became  so  intense 
that  she  could  not  take  a  long  inspiration  without  ci-ying  out.  Patient 
was  never  free  from  pain  and  tenderness  in  region  of  duodenum,  but 
the  intense  pain  was  decidedly  paroxysmal ;  sometimes,  but  not  al- 
wavs,  the  paroxysms  seemed  to  be  induced  by  patient  moving  or  tak- 
ing a  long  inspiration.  Pulse  varied  from  100  to  120  ;  cheeks  fluslied, 
but  no  perspirations  ;  much  thirst,  but  even  fluids  were  at  once  re- 
jected from  stomach.  Jaundice  diminished  ;  motions  always  contained 
bile,  and  at  last  were  almost  natural  in  appearance.  All  treatment 
failed  to  give  relief  ;  patient  became  rapidly  emaciated,  and  was  occa- 
sionally delirious  during  night ;  and  towards  the  end  tongue  was  dry 
and  brown,  and  sordes  collected  on  lips  and  teeth.  Death  took  place 
on  Dec.  23. 

On  post-mortem  examination  liver  was  found  to  be  large,  and  en- 
tire substance  of  both  lobes  studded  with  an  immense  number  of  cir- 
cumscribed abscesses,  vaiying  in  size  from  a  pea  to  a  small  orange,  and 
filled  with  yellow  flaky  pus ;  outer  surface  glued  by  recent  lymph  to 
diaphragm  and  adjoining  organs.  Hepatic  and  common  ducts  pervious 
and  contained  bile.  Gall-bladder  collapsed,  its  cavity  being  scarcely 
larger  than  a  hazel-nut,  and  its  coats  much  thickened.  A  gall-stone, 
somewhat  larger  than  a  pea,  was  found  impacted  at  commencement  of 
cystic  duct,  and  mucous  membrane  in  contact  with  the  concretion  was 
ulcerated,  and  partly  converted  into  a  blackish  slough.  Beyond  this 
cystic  duct  vras  obliterated.  Gall-bladder  contained  about  a  dozen 
calculi  of  smaller  size,  but  no  bile ;  fundus  firmly  adherent  to  duode- 
num, and  between  these  two  viscera  was  a  closed  cavity  containing 
gall-stones,  equalling  in  size  and  number  those  found  in  gall-bladder 
itself ;  corresponding  mucous  surfaces  of  duodenum  and  of  gall- 
bladder marked  by  an  extensive  cicatrix.  These  appearances  were  pro- 
bably the  result  of  a  dire  ct  passage  of  gall-stones  through  the  fundus 
of  the  gall-bladder  into  the  bowel  in  the  attack  two  years  before  death. 
Mucous  membrane  of  first  three  inches  of  duodenum  intensely  injected 
but  not  ulcerated ;  inner  surface  of  the  stomach  and  intestines  pre- 
sected  nothing  abnormal.  Spleen  was  four  times  its  normal  size.  In 
addition  to  the  coating  of  recent  lymph,  cajisule  of  liver  at  several 
places  presented  old  thickening  and  firm  adhesions.  Lungs  congested, 
but  otherwise  normal. 

The  following  case  is  interesting  from  its  remarkably  latent 
character,  and  for  the  absence  of  pyrexia.  The  coexistence  of 
plugging  of  tlie  femoral  vein  with  enlargement  and  tenderness 
of  the  liver,  bile-pigment  in  urine,  and  sallowness  of  the  skiii 
suggested  that  the  patient  might  be  suffering  from  pyaemic  in- 
flammation of  the  liver,  and  this  diagnosis  was  made,  notwith- 


LECT.  V.  PYEMIC    ABSCESSES.  I75 

standing  tlie  absence  of  rigors  or  perspirations,  which  are  not 
unfreqnently  absent  in  pyseniia  arising  from  internal  causes.  I 
was,  however,  scarcely  prepared  to  meet  with  pjsemic  inflamma- 
tion of  the  liver  with  no  elevation  of  temperature,  during  at 
least  five  successive  days,  which  this  case  shows  to  be  possible. 

Case  LXXII. — Gall-stones  causing  Ulceration  and  Perforation  of  Cystic 
Duct — Pt/oemic  Hepatitis  and  Thrombosis  of  Femoral  Vein — Absence 
of  Pyrexia. 

Mary  Ann  S ,  aged  .53,  adm.  into  Middlesex  Hosp.   April  13, 

1869.  I^ever  had  any  symptoms  pointing  to  gall-stones,  and  except- 
ing diseases  of  childhood,  had  enjoyed  good  health,  and  been  able  to 
work  as  charwoman  till  three  months  before  admission,  when  she  began 
to  complain  of  excruciating  pain  and  swelling  in  right  leg,  and  lost 
appetite  and  flesh.  She  continued  going  about,  however,  till  ten  days 
before  admission,  when  she  was  seized  with  rather  severe  pain  in  epi- 
gastrium, nausea,  vomiting,  thirst,  and  increased  prostration. 

On  admission  patient  was  of  stout  habit,  very  prostrate,  dejected 
and  apathetic.  She  was  also  very  restless  and  sleepless  at  night,  but 
she  had  no  headache  or  delirium  and  her  memory  was  good.  Her  chief 
complaint  was  uncontrollable  vomiting,  so  that  she  could  retain  nothing 
on  her  stomach.  Much  thirst ;  tongue  red  and  dry  all  over.  Decided 
tenderness  in  epigastrium  and  below  right  ribs  ;  liver  extended  2  in, 
beyond  ribs  in  right  nipple  line,  where  it  measured  vertically  5  in. ;  its 
surface  smooth.  No'  ascites  or  enlargement  of  spleen  ;  bowels  regular. 
Pulse  84,  feeble  ;  physical  signs  of  heart  and  lungs  normal  ;  skin  cool ; 
no  eruption  ;  temp.  98°  Fahr.  Urine  contained  bile-pigment,  but  no 
albumen.  Face  slightly  sallow,  but  conjunctivee  white.  Right  thigh 
and  leg  swollen  throughout ;  and  great  tenderness  along  whole  course 
of  right  femoral  vein. 

Treatment  consisted  mainly  in  giving  milk  and  ice  by  mouth,  and 
brandy  and  beef-tea  by  rectum  ;  but  patient  continued  to  sink.  On 
April  16  hiccup  set  in,  with  coffee-ground  vomiting,  and  watery 
motions  containing  blood.     Death  occurred  on  April  18, 

Neither  before  nor  subsequently  to  admission  into  hospital  had  pa- 
tient at  any  time  rigors  or  perspirations  ;  and  during  whole  time  that 
she  was  under  observation,  although  temperature  was  taken  twice 
daily,  at  no  time  did  it  rise  above  98°  Fahr,  in  axilla,  and  only  once 
did  it  reach  99f°  under  tongue. 

Autopsy. — Two  and  a  half  inches  of  fat  in  abdominal  parietes. 
Right  iliac  and  femoral  veins  plugged  throughout,  coagulum  for  3  or 
4  in.  at  brim  of  pelvis  being  decolorised  and  adherent,  but  below  this 
black  and  non-adherent.  Liver  adherent  to  duodenum  and  colon,  and 
on  removing  it  gall-bladder  was  torn  across,  allowing  a  number  of  poly- 
hedral gall-stones  about  size  of  plum-stones,  and  covered  with  pus,  to 


1/6  ENLARGEMENTS    OF   THE    LIVER.  lect.  v. 

escape.  These  gall-stones  had  been  enclosed  in  a  cavity  bounded  by- 
liver  and  surrounding  parts,  with  its'  internal  surface  ulcerated,  and 
communicating  by  a  large  ragged  opening  with  cystic  duct.  Beyond 
this,  cystic  duct  was  closed  by  adhesions,  but  hepatic  duct  was  per- 
vious. No  bile  in  gall-bladder.  Liver  studded  with  numerous  inflam- 
matory deposits,  up  to  size  of  a  cherry,  most  of  them  consisting  of  a 
firm,  translucent,  greyish  material,  which  in  some  instances  was  soften- 
ing into  an  opaque  fluid,  like  pus.  The  firmer  material  was  made  up 
of  branched  fibre-cells  ;  and  the  yellow  fluid  of  oil-globules  and  com- 
pound granular  bodies,  but  no  true  pus-corpuscles.  The  intervening 
portions  of  liver,  spleen,  and  kidneys  were  soft,  apparently  from  rapid 
decomposition.  Heart  flabby,  its  lining  jnembrane  stained  with  blood- 
pigment.     Lungs  congested,  with  small  sub-pleural  ecchymoses. 

Case  LXXIII.  was  remarkable  for  the  large  size  attained  by 
the  liver,  and  for  the  absence  of  any  cause  of  the  hepatic  in- 
flammation, excepting  the  softening  tubercle  in  the  mediastinal 
glands. 

Case  LXXIII. — Multiple  Abscesses  of  Liver — Softening  Tubercle  in 
Mediastinal  Glands. 

Ann  C ,  aged  5'/,  a  cook,  adm.  into  Middlesex  Hosp.  under  my 

care  Jan.  13,  1868.  Her  father  and  mother  had  both  lived  to  upwards 
of  80,  and,  with  exception  of  an  umbilical  hernia  and  a  great  tendency 
to  vertigo,  she  herself  had  always  enjoyed  good  health  until  her 
present  illness,  which  commenced  a  week  before  Christmas  with  acute 
pain  in  region  of  liver,  stretching  round  back  to  left  side.  This  pain 
was  accompanied  by  febrile  symptoms,  loss  of  appetite  and  sleep,  and 
by  a  swelling  and  tightness  in  upper  part  of  abdomen,  which  increased 
daily.  On  Jan.  5  her  face  and  eyes  had  been  noticed  to  be  slightly 
yellow. 

On  admission  patient  was  an  extremely  corpulent  woman,  whose 
skin  and  conjunctivae  presented  a  slightly  jaundiced  tint,  and  who  was 
so  weak  as  to  move  her  great  bulk  with  ditficulty  in  bed.  The  abdo- 
men was  enormously  enlarged,  measuring  53  in.  at  umbilicus.  Mode- 
rate oedema  of  both  lower  extremities,  but  no  distinct  thrill  of  fluid 
in  abdomen,  and  percussion  yielded  a  clear  sound  in  both  flanks.  The 
great  size  of  abdomen  appeared  due  partly  to  an  enormous  subcuta- 
neous deposit  of  fat,  and  partly  to  enlaroementof  liver,  which  measured 
9  in.  in  right  mammary  line,  and  which  reached  fully  5  in.  below  margin 
of  right  ribs.  8o  far  as  an  examination  could  be  made  through  the 
thickened  abdominal  parietes,  enlargement  of  oman  appeared  to  be 
uniform  in  every  directioTi,  and  its  surface  was  hard  and  smooth.  On 
pressure  over  it  there  was  decided  tenderness,  and  a  pain  shooting  from 
point  of  pressure  to  back.  Tongue  dry  and  red  down  centre ;  much 
thirst ;    no   vomiting  ;    bowels  regular.     Pulse  108.     Heart's  sounds 


i^ECT.  V.  TROPICAL   ABSCESS.  I// 

very  feeble,  but  no  bellows-murraur.  Respirations  embarrassed  and 
thoracic  ;  sonorous  rales  at  bases  of  both.  Inngs.  Urine  of  a  dark 
'  amber  colour,  with  a  copious  deposit  of  litbates  ;  no  albumen.  Mind 
clear.     Temperature  98°  Fabr. 

Patient  was  ordered  the  day  after  admission  a  draught  containing 
a  drachm  of  sulphate  of  magnesia  three  times  a  day,  but  on  Jan.  15, 
after  three  doses,  bowels  were  so  purged  that  a  mixture  of  nitro-hydro- 
chloric  acid  and  gentian  was  substituted.  Diari-hoea,  however,  per- 
sisted, motions  being  watery  and  dark-brown  ;  tongue  continued  dry  ; 
temperature  rose  to  101 '4°  ;  on  nights  of  Jan.  17  and  18  patient  had 
much  low  delirium  ;  and  in  afternoon  of  Jan.  19  she  died  suddenly  by 
syncope  while  attempting  to  get  out  of  bed. 

Autopsy. — Fat  in  abdominal  parietes  measured  fully  4  in.  in 
thickness.  Peritoneum  contained  about  three  pints  of  turbid  serum, 
with  small  flakes  of  lymph.  Liver  enormously  enlarged,  its  lower 
margin  projecting  about  5  in.  beyond  that  of  right  ribs ;  it  weighed 
266  ounces,  and  was  studded  throughout  with  innumerable  minute 
abscesses,  the  projection  of  which  from  outer  surface  gave  to  this  a 
coarsely  granular  aspect.  The  portions  of  hepatic  tissue  which  re- 
mained were  in  an  advanced  state  of  fatty  degeneration,  but  there  was 
scarcely  a  quarter  of  an  inch  of  organ  free  from  purulent  deposit. 
Gall-bladder  much  distended  with  innumerable  black  polygonal  con- 
cretions, from  size  of  a  small  cherry  to  that  of  a  grain  of  sand;  ma- 
jority were  small,  and  resembled  grains  of  coarse  gunpowder  ;  the 
larger  ones  were  found  on  section  to  be  white  internally,  and  to  be 
composed  of  cholesterin.  Common  bile-duct  patent,  and  after  careful 
examination,  no  ulceration  could  be  discovered  in  lining  membrane  of 
gall-bladder  or  of  any  of  ducts,  nor  in  mucous  membrane  of  stomach 
or  intestines.  No  pus  in  portal  vein  or  embolism  of  hepatic  artery. 
Spleen  large  and  soft.  Kidneys  rather  large  and  pale,  but  appeared 
normal.  Right  Fallopian  tube  dilated  into  a  cyst  the  size  of  an  orange, 
containing  a  dark  thin  fluid,  and  with  several  small  vegetations  at- 
tached to  its  lining  membrane.  A  fibrous  tumour  size  of  a  walnut  in 
walls  of  uterus.  At  apices  of  both  lungs  there  were  old  tubercular 
cicatrices,  but  no  cavities,  and  in  anterior  mediastinum  were  two  or 
three  collections  of  pns,  formed  by  suppuration  of  tubercular  lymphatic 
glands.  Heart  pale,  flabby,  and  friable,  and  in  an  advanced  stage  of 
fatty  degeneration. 


X.    TROPICAL    HEPATITIS    AND    ABSCESS    OF    THE    LIVER. 

The  pathology  of  tropical  abscess  of  the  liver  has  been  a 
subject  of  much  discussion,  and  one  on  which  opinions  are  still 
divided.  The  frequent  coexistence  in  the  tropics  of  abscess  of 
the  liver  with  dysentery  has  naturally  led  pathologists  to  con- 

N 


178  ENLARGEMENTS    OP    THE    LIVER.  lect.  v. 

nect  the  two  lesions,  some,  like  Annesley,  maintaining  that  the 
dysentery  is  the  result  of  the  hepatitis  ;  others,  that  the  hepa- 
titis is  the  result  of  the  dysentery ;  while  a  third  class,  like  Dr. 
Abercrombie,  have  suggested  that  the  frequent  concurrence  of 
the  two  maladies  is  merely  the  result  of  accident.  The  doctrine 
now  most  generally  accepted  in  this  country  is  that  propounded 
nearly  thirty  years  ago  by  Dr.  G.  Budd,  viz.  that  the  hepatic 
inflammation  is  the  result  of  purulent  absorption  from  the 
ulcerated  colon,  or  in  fact  that  the  pathology  of  tropical  abscess 
is  identical  with  that  of  the  pysemic  abscesses  of  this  country.* 

Considering  how  frequently  in  this  country  abscess  of  the 
liver  is  secondary  to  ulcers  of  the  bile-ducts,  stomach,  or  bowels, 
or  other  sources  of  purulent  absorption,  it  would  indeed  be 
extraordinary  if  dysenteric  ulceration  of  the  colon  never  led  to 
a  like  result,  as  some  have  contended.  The  fact  that  fatal 
dysentery  with  ulceration  uncombined  with  hepatic  abscess  is 
a  common  occurrence  in  India  is  no  argument  against  hepatic 
abscess  occasionally  resulting  from  dysentery,  any  more  than 
that,  in  Europe,  pysemic  abscesses  only  occur  in  exceptional 
cases  of  intestinal  ulceration,  or  of  the  other  sources  of  purulent 
absorption  already  enumerated.  Something  more  than  an  open 
sore  is  necessary  for  the  formation  of  pysemic  deposits.  The 
discharges  from  the  sore  must  be  in  a  peculiar  state  of  decom- 
position. The  causes  of  this  decomposition  may  be  extrinsic 
or  intrinsic,  but  where  there  is  no  such  decomposition  there 
is  no  pyaemia. 

But  a  large  number  of  the  abscesses  of  the  liver  met  with 
in  tropical  countries  cannot  be  ascribed  to  dysentery,  or  to  a 
pysemic  origin,  or  to  mechanical  injury.  More  than  twenty 
years  ago,  I  stated  that  this  was  the  result  of  my  observations 
on  the  diseases  of  Burmah,'^  and  the  facts,  which  have  since 
been  published  by  Morehead,^  Bristowe,*  Frerichs,*  McLean,^ 
and  others,  appear  to  me  to  be  perfectly  conclusive  on  the 
matter.     These  facts  are  of  a  fourfold  nature. 

1.  Cases  are  not  uncommon  in  tropical  countries  where 
there  has  been  abscess  of  the  liver,  and  where  the  j^atient  has 

'  Dis.  of  Liver,  3rd  ed.  ]>.  82. 

-  Oliscrv.  on  the  Climaii;  and  Diseases  of  Burmali.     Edin.  Med.  and  Surg.  Joiirn. 
1854,  pp.  215-7. 

'  Researches  on  Diseases  in  India,  1856,  ii.  p.  10. 

«  Path.  Trans.  1858,  ix.  p.  260. 

'  Frerichp,  Treatise  on  Dis.  of  Liver,  Eng.  Ed.  ii.  p.  116. 

•  Article  on  Suppurative  lufl.  of  Liver,  in  Jiycnoldss  System  of  Med.  iii.  p.  324. 


LECT.  V.  TROPICAL    ABSCESS.  1 79 

recovered  without  any  symptoms  of  dysentery  before,  during, 
or  after  the  hepatic  malady.  I  shall  give  you  the  particulars  of 
such  a  case  immediately  (Case  LXXIV.). 

2.  In  many  cases  where  there  has  been  a  concurrence  of 
hepatic  abscess  and  dysentery,  the  symptoms  of  the  former 
malady  have  preceded  those  of  the  latter.  A  case  of  this  sort 
was  recorded  by  me  in  the  eighth  volume  of  the  '  Pathological 
Transactions'  (p.  237),  and  similar  cases  are  referred  to  by 
Morehead,  Waring,  and  Bristowe.* 

It  may  perchance  be  argued  that  in  the  cases  included  under 
these  two  heads  dysenteric  ulceration  was  really  present,  but 
that  its  symptoms  were  latent.  Dr.  Dickinson,  for  instance, 
has  recorded  a  case  where  extensive  dysenteric  ulceration  and 
a  large  abscess  of  the  liver  were  found  after  death  without  any 
symptoms  during  life  to  lead  to  a  suspicion  of  either  malady.^ 
But  although  such  an  explanation  may  apply  in  a  few  excep- 
tional eases,  it  is  obviously  inapplicable  to  such  results  as  those 
obtained  by  Mr.  Waring,  who  states  that  of  300  cases  of  hepatic 
abscess  proving  fatal  in  India,  in  only  82  cases,  or  in  27*3  per^ 
cent.,  was  the  hepatitis  preceded  by  symptoms  of  dysentery.^ 

3.  The  most  conclusive  cases,  however,  are  those  in  which 
the  patient  has  died  of  hepatic  abscess,  and  no  sign  of  dysen- 
teric ulceration  has  been  found  after  death.  I  shall  give  you 
immediately  the  details  of  a  case  of  this  sort,  in  which,  it  is 
important  to  add,  there  had  been  a  considerable  amount  of 
diarrhoea  during  life  (Case  LXXIV.).  Morehead  observed  21  fatal 
cases  of  abscess  of  the  liver  '  without  any  sign  of  intestinal 
ulceration,'^  while  in  204  cases  of  abscess  of  the  liver  collected 
by  Waring  there  were  no  ulcerations,  cicatrices,  or  abrasions 
in  51,  or  in  exactly  one- fourth.^  Lastly,  in  the  Pathological 
Museum  at  Netley  there  are  48  specimens  of  tropical  abscess  of 
the  liver,  of  which  in  34  the  abscess  was  uncomplicated  with  any 
intestinal  lesion.^ 

It  is  clear,  therefore,  that  although  dysenteric  ulceration 
of  the  bowel  may  occasionally  lead  to  pysemic  deposits  in  the 
liver  similar  to  those  met  with  in  this  country,  many  cases  of 
tropical  abscess  are  independent  of  such  an  origin.     Few  Indian 

'  Dr.  James  Finlayson  has  pointed  out  how  hepatic  abscess  may  lead  to  congestion 
and  even  ulceration  of  the  colon.     Glasgow  Med.  Journ.,  Feb.  1873. 

2  Path.  Trans.  1862,  vol.  xiii.  p.  120. 

^  An  Enquiry  into  the  Statistics  and  Pathology  of  Abscess  of  the  Liver.     Trt^van- 
drum,  1864. 

*  Op.  cit.  ii.  p.  12.  '  Op.  cit.  «  McLean,  op.  cit.  iv.  324. 

N  2 


l80  ENLARGEMENTS    OF   THE    LIVER.  iect.  v. 

physicians  wouW,  I  think,  admit  the  validity  of  Dr.  Moxon's 
argutnent  that  intestinal  ulceration  or  cicatrices  would  be  found 
in  all  cases  of  tropical  abscess  of  the  liver  if  the  bowels  were 
examined  with  sufficient  care.' 

4.  It  appears  to  me  that  the  etiolosry  of  hepatic  abscess 
receives  further  elucidation  from  an  anatomical  point  of  view. 
The  abscesses  of  the  liver  which  are  met  with  in  this  country, 
and  which  are  the  result  of  absorption  from  an  open  sore,  are 
usually,  if  not  always,  small  but  numerous.  On  the  other  hand, 
in  most  cases  where  abscess  of  the  liver  is  met  with  in  the 
tropics,  there  is  but  one  abscess  which  attains  to  large  dimen- 
sions, or  in  exceptional  cases  there  may  be  two  or  three.  In  a 
case  recently  under  my  care  160  ounces  of  pus  were  drawn  off 
by  tapping  during  life.  Abscesses  of  the  liver,  answering  to 
this  description,  are  almost  unknown  in  this  climate  or  in 
temperate  climates  generally,  except  in  persons  who  have  sus- 
tained some  local  injury  of  the  liver,  or  who  have  at  one  time 
resided  in  the  tropics — an  extraordinary  fact,  if  their  cause  be 
the  same  as  that  of  multiple  abscesses.  Even  when  dysentery 
occurs  in  temperate  climates  no  such  abscesses  are  found  iu 
connection  with  it.  Out  of  many  hundreds  of  cases  of  dysentery 
which  occurred  in  Millbank  Prison  during  thirty  years,  we  are 
told,  on  the  authority  of  the  late  Dr.  Baly,  that  not  one  was 
complicated  with  hepatic  abscess.'^  In  Germany,  it  is  stated  by 
Heubner,  that  hepatic  abscesses  are  sometimes  met  with  after 
dysentery  ;  '  they  are,  however,  multiple  and  of  embolic  source,' 
and  it  is  added  that  these  abscesses  ought  not  to  be  confounded 
with  the  ordinary  abscess  of  the  tropics.^  These  facts  alone 
are  sufficient  to  show  that  tropical  abscess  of  the  liver  is  inde- 
pendent of  dysentery.  To  argue  that  the  large  size  and  singleness 

'  P;ifh.  Trans.,  1873,  xxiv.  116. 

^  '  Wlien  the  close  relation  subsistinpr  between  dysentery  and  suppurative  di.sease 
of  the  liver  is  considered,  it  cannot  but  appear  remarkable  that  amongst  the  many 
hundreds  of  ca.se.s  of  dysentery  which  have  occurred  in  the  Millbank  Prison  durinfrthe 
last  seven  years,  rot  one  has  been  complicated  witli  hepatic  abscess.  The  medical 
records  of  the  establishment,  too,  which  reach  back  to  the  year  1824,  afford  no  grounds 
for  even  a  suspicion  that  such  cases  ever  occurred  amongst  the  prisoners.'  Yet,  '  in 
this  dysentery  in  the  Millbank  Prison  the  disease  of  the  mucous  surface,  both  as  to  it« 
seat  and  in  its  nature,  has  lioen  the  same  as  in  the  dysentery  of  India,  with  which 
hepatic  abscess  is  so  frequently  as.tociated.'     Gulstonian  Lectures  on  Dysentery,  1847. 

»  On  Dysentery.  Ziemsscu's  Cyclop,  of  Med.,  Anier.  Ed.  1875,  i.  546.  556.  Roki- 
tansky  also,  in  his  dissections  of  casps  of  dysentery,  never  found  the  liver  visibly 
diseased  ;  while  in  I'rance,  T?roussais,  who  reported  17  fatal  cases  of  dysentery  with 
dissections,  does  not  mention  his  having  found  al'.scess  of  the  liver  in  any  one  instance, 
although  the  condition  of  this  organ  is  frequently  mentioped.     Baly,  op.  clt. 


XECT.  V,  TROPICAL    ABSCESS.  l8l 

of  the  tropical  abscess  is  due  to  the  longer  time  it  lasts  as  com- 
pared with  the  swift  course  of  the  multiple  abscesses  met  with 
in  pytemia  ^  is,  it  appears  to  me,  to  disregard  the  clinical  history 
of  the  two  maladies  ;  in  the  tropics  one  enormous  abscess  may 
form  in  a  fortnight,  but  both  m  tropical  and  temperate  climates 
small  multiple  abscesses  may  be  found  after  an  illness  which 
has  lasted  for  months. 

For  these  reasons  I  have  proposed  to  designate  the  single 
large  abscess  so  common  in  warm  climates  the  Tropical  Abscess, 
to  distinguish  it  from  the  Pycemic  Abscess  which  is  the  com- 
mon form  in  this  country. 

In  suggesting  these  designations  it  is  not  contended  that 
small  multiple  abscesses  of  the  liver  are  unknown  in  the  tropics  ;^ 
but,  so  far  as  i  have  been  able  to  ascertain,  this  form  is  never 
met  with  except  in  connection  with  dysentery,  or  with  some  other 
source  of  purulent  absorption.  It  must  not  be  forgotten  that  a 
single  large  abscess,  like  a  suppurating  hydatid  in  the  liver, 
may  be  a  source  of  infection  and  of  small  secondary  abscesses. 
The  single  tropical  abscess  may  also  coexist  with  dysentery,  but 
from  the  large  number  of  cases  in  which  both  dysentery  and 
hepatic  abscess  are  independent  of  each  other,  it  follows  that 
when  they  coexist,  they  are  either  the  effects  of  a  common 
cause,  which  in  certain  persons  will  produce  either  of  the 
diseases  separately,  or  of  a  concurrence  of  causes  which  indi- 
vidually will  cause  only  one  of  the  diseases.  The  latter  view 
is  favoured  by  the  fact  that  a  single  large  abscess  is  not  found 
in  connection  with  dysentery  in  temperate  climates.  Supposing, 
for  example,  what  is  probably  the  truth,  that  dysentery  is  the 
result  of  a  poison  inhaled,  or  swallowed  in  drinking  water,  and 
that  hepatitis  may  be  caused  by  a  chill  in  a  person  whose  liver 
has  been  congested  by  a  residence  in  a  hot  climate,  aided  by 
intemperance,  irritating  ingesta,  and  exposure  to  the  malaria 
of  tropical  fevers  (see  p.  184),  it  is  readily  conceivable  that  in  a 
country  like  India  where  these  causes  so  often  operate  simul- 
taneously, attacks  of  dysentery  and  hepatitis — combined  as  well 
as  separate — should  not  be  uncommon. 

The  distinction  drawn  above  between  pysemic  and  tropical 

'  Moxon,  loc.  cit. 

^  Of  300  cases  of  abscess  of  the  liver  in  India  collected  by  Waring,  the  number  of 
abscesses  was  not  stated  in  12  ;  of  the  remaining  288,  there  was  one  abscess  in  177  ; 
two  abscesses  in  33;  three  in  11 ;  tour  in  17  ;  five  to  ten  in  10;  more  than  ten  m 
40.  An  Enquiry  into  the  Statistics  and  Pathology  of  some  Points  connected  wich 
Abscess  of  the  Liver,  as  met  Avith  in  the  East  Indies.     Trevaadrum,  ISoA,  p.  125. 


l82  ENLARGEMENTS    OF    THE    LIVER.  lect.  V. 

abscess  is  far  from  being  one  merely  of  pathological  curiosity  ; 
it  has  a  most  important  bearing  both  on  prognosis  and  treat- 
ment. The  pysemic  abscess  is  much  the  more  serious  and  fatal 
malady  of  the  two  ;  the  danger  is  from  the  blood-poison  and 
not  from  the  local  disease ;  and  recovery  from  it  rarely,  if  ever, 
occurs.  The  tropical  abscess  again  is  a  local  malady,  not  un- 
frequently  recovered  from ;  the  abscess  may  discharge  itself 
through  the  lung,  the  stomach,  or  the  bowel,  or  externally,  and 
thus  the  patient  may  recover — terminations  not  met  with  in 
the  case  of  pysemic  abscesses ;  and  lastly,  one  of  these  natural 
modes  of  termination  of  the  tropical  abscess  is  advantageously 
imitated  by  the  surgeon,  when  he  evacuates  the  abscess  by  an 
external  opening — a  procedure  which  would  obviously  be  worse 
than  useless  in  the  pya3mic  abscess.  It  follows,  therefore, 
that  it  is  of  some  practical  importance  to  be  able  to  distin- 
guish during  life  between  the  pysemic  and  the  tropical  abscess. 
The  characters  of  the  former  have  been  already  detailed ; 
those  of  the  latter  remain  to  be  considered.  They  are  as 
follows  : — 

A.  In  the  early  stage  of  the    disease,  the   main   clinical 
features  are  those  of  hepatic  congestion  already  described  (see 
p.  131).     There  is  chilliness  followed  by  pyrexia,  often  of  a  re- 
mittent type,  accompanied  b}'  pain  and  tenderness,  or  oftener  by 
a  feeling  of  weight,  fulness,  or  uneasiness  in  the  region  of  the 
liver,  and  occasionally  by  pain  in  the  right  shoulder,   defective 
respiratory  movement  of  the  right  ribs,  dry  cough,  a  uniformly 
augmented  area  of  hepatic  dulness,  and  slight  jaundice.      The 
enlargement,  however,  is  on  the  whole  less,  and  the  jaundice 
much  rarer  than  in  the  congestion  of  the  liver  resulting  from 
disease  of  the  heart  or  lungs.     This  is  due  to  the  circumstance 
that  the  branches  of  the  hepatic  and  portal  veins,  which  are 
gorged  in  the  latter  case,  are  much  larger  than  those  of  the 
hepatic  artery,  which  are  the  main  seat  of  the  congestion  that 
precedes  the  formation  of  abscess.     But   in  not    a  few  cases 
there  are  no  local  signs  of  mischief  in  the  liver,  and  in  fact 
the  only  symptoms  may  be  those  of  an  intermitting  or  remitting 
fever  which  may  be  thought  to  be  malarious, 

B.  When  the  inflammation  goes  on  to  suppuration,  which 
iiuless  it  terminate  previously  by  resolution,  often  occurs  at 
the  end  of  a  week  or  twelve  days,  the  characters  are  as 
follows : — 

1.  There  is  enlargement  of  the  liver,  which  is  no  longer  uni- 


LECT.  V.  TROPICAL    ABSCESS.  1 83 

form.  The  natural  outline  of  the  area  of  hepatic  dulness  is  altered, 
and  will  bulge  upwards,  downwards,  forwards,  or  outwards, 
according  to  the  direction  which  the  abscess  takes  in  each  case 
(see  fig'.  17,  page  193).  Not  unfrequently  there  is  a  bulging  of 
the  ribs,  with  obliteration  of  the  intercostal  spaces,  or  there  is 
a  prominence  in  the  epigastrium,  or  in  the  right  hjpochondrium, 
such  as  occurs  in  hydatid  tumours. 

2.  This  bulging  or  tumour  is  tense,  rounded,  smooth,  and 
free  from  any  inequalities.  In  the  advanced  stage,  however,  of 
exceptional  cases  the  margin  of  the  enlarged  liver  may  be 
nodulated  from  the  development  in  it  of  small  secondary 
pysemic  abscesses. 

3.  Fluctuation  can  usually  be  detected  in  the  tumour,  which 
will  be  more  or  less  distinct  according  to  the  distance  of  the 
abscess  from  the  surface.  The  feeling  of  vibration,  however, 
which  can  often  be  appreciated  on  tapping  with  the  finger  over 
a  hydatid  tumour  (page  56),  cannot  be  elicited  in  an  abscess, 
owing  to  the  greater  thickness  of  its  contents.  Another  dis- 
tinctive character  of  abscess  is,  that  the  fluctuation  is  usually 
surrounded  by  a  mass  of  inflammatory  hardness. 

But  although  tropical  abscess  is  a  common  cause  of  enlarge- 
ment of  the  liver,  an  abscess  of  considerable  size,  if  deeply 
seated,  may  cause  no  apparent  fluctuation,  bulging,  or  even  en- 
largement. This  is  a  fact  which  I  cannot  too  strongly  impress 
upon  your  memories. 

4.  Pain  and  tenderness  are  very  often  absent.  Pain,  when 
present,  is  dull  and  heavy,  and  not  of  that  acute  chara.cter,  in 
the  first  instance,  at  all  events,  so  common  in  the  pysemic  abscess. 
This  is  because  the  abscess  is  usually  at  first  in  the  interior  of 
the  liver.  The  pain  only  becomes  acute  like  that  of  pleurisy, 
and  the  tenderness  great,  when  the  matter  approaches  the 
surface  of  the  liver  and  excites  peri-hepatitis,  or  stretches  the 
integuments.  Thus  it  is  that  acute  pain  often  marks  the  last 
stage,  instead  of  the  commencement,  of  the  morbid  process. 
Some  cases  are  remarkably  latent,  as  far  as  pain  is  concerned, 
throughout  their  whole  course  ;  while  in  others  pain  is  only 
produced  when  the  patient  takes  a  long  breath,  and  at  the  same 
time  pressure  is  made  below  the  margin  of  the  ribs,  or  over  the 
lower  end  of  the  sternum.  A  sympathetic  pain  in  the  right 
shoulder  is  not  uncommon,  especially  when  the  abscess  is 
situated  on  the  convex  surface  of  the  right  lobe ;  but  in  most 
cases  it  is  absent.     The  presence  of  pain  in  the  shoulder  will 


184  ENLAEGEMENTS    OF    THE    LIVER.  lect.  v. 

undoubtedly  increase,  althougli  its  absence  will  not  diminish, 
the  importance  of  other  symptoms. 

5.  Ascites,  oedema  of  the  lower  extremities,  enlargement  of 
the  superficial  veins  of  the  abdomen,  and  haemorrhoids  are  not 
distinguishing  characters  of  tropical  abscess,  any  more  than  of 
hydatid  of  the  liver.  Their  occurrence  in  rare  cases  is  accidental, 
and  due  to  compression  by  the  tumour  of  the  trunk  of  the  portal 
vein  or  of  the  inferior  vena  cava.  Occasionally,  fluid  is  thrown 
out  into  the  peritoneum  as  the  result  of  peritonitis. 

6.  Enlargement  of  the  spleen  is  rarely  present  in  tropical 
abscess. 

7.  Jaundice  is  a  much  rarer  symptom  in  the  tropical  than 
in  the  pysemic  abscess.  Its  occurrence,  in  fact,  if  we  except  a 
slight  icteric  tint  during  the  primary  stage  of  congestion,  is 
quite  exceptional.  Morehead  has  noted  it  in  only  five  out  of  up- 
wards of  120  cases. ^  When  it  occurs,  it  has  mostly  a  mechani- 
cal origin,  and  is  due  to  the  concurrence  of  catarrh  of  the  bile- 
ducts,  or  to  the  direct  compression  of  the  large  ducts  by  the 
abscess. 

8.  The  constitutional  symptoms  are  important,  as  serving 
to  distinguish  the  tropical  abscess  from  hydatid  tumour, 
and  also  from  the  fact  that  in  the  absence  of  local  signs  the 
diagnosis  must  be  founded  upon  them  alone.  After  the  occur- 
rence of  suppuration,  they  are  mainly  progressive  emaciation 
and  fever  of  the  hectic  type.  The  frequency  of  the  pulse  may 
be  little,  if  at  all,  increased  ;  but  (unless  the  abscess  has  become 
encysted  and  quiescent)  there  is  almost  always  an  elevation  of 
temperature  to  several  degrees  at  some  period  of  the  twenty- 
four  hours.  Rigors  and  night-sweats  are  less  prominent 
symptoms  than  in  the  pysemic  abscess.  The  tongue  becomes 
covered  with  a  grey  or  yellowish  coat,  and  in  the  advanced  stage 
it  may  be  preternaturally  red  and  dry  and  coated  with  aphthae. 
Loss  of  appetite  is  a  common,  but  far  from  invariable,  symj)tom. 
Obstinate  vomiting  is  present  in  many  cases,^  and  ought  always 
to  excite  suspicion  of  abscess  of  the  liver  in  a  tropical  climate; 
it  is  very  apt  to  occur  when  the  abscess  is  about  to  discharge 
into  the  stomach  or  duodenum,  and  the  exhaustion  which  it 
entails  may  be  tbe  immediate  cause  of  death.  Diarrhoea,  or 
even  dysentery,  occurs  in  some  cases.    The  urine  is  loaded  with 

»  Res.  on  Dis.  in  India,  2nd.  ed.  1860,  p.  37-3. 

•^  See  Dr.  W.  C.  Maclean  and  Sir  Josopli  Fayrer,  Brit.  Med   Journ.  1874,  ii.  138, 
4(11. 


LECT.  V.  TROPICAL    ABSCESS.  1 85 

lithates  or  litliic  acid,  and  contains  mucli  pigment;  the  urea  is 
greatly  increased,  but  when  the  hepatic  tissue  has  been  in  great 
measure  destroyed,  it  may  be  deficient.  Temporary  albuminuria, 
often  considerable,  is  not  uncommon.  Very  often  there  is  a 
short  dry  cough,  and  the  respirations  are  quickened,  especially 
when  the  abscess  is  about  to  perforate  the  diaphragm,  and  then 
also  friction  may  be  heard  at  the  base  of  the  right  lung. 

It  is  important  to  remember,  however,  that  a  tropical 
abscess  of  the  liver  may  be  so  latent  as  to  reveal  itself  by 
neither  local  signs  nor  constitutional  symptoms.  Not  unfre- 
quently  the  only  symptoms  are  debility  and  paroxysms  of  fever, 
which  are  believed  to  be  malarious,  but  the  real  nature  of  which 
is  first  suspected  by  their  failing  to  yield  to  large  doses  of 
quinine.  In  some  cases,  as  we  shall  presently  find,  even  pyrexia 
may  be  absent. 

9.  The  duration  of  tropical  abscess  of  the  liver  is  a  matter  of 
some  importance  in  diagnosis.  Although  it  may  terminate  fatally, 
or  may  discharge  in  some  direction  within  three  weeks  of  the 
commencement  of  the  symptoms,  yet,  on  the  whole,  the  course 
of  the  disease  is  less  rapid  than  that  of  the  pysemic  abscess. 
Very  often  it  extends  over  two,  three,  or  even  six  months ;  and 
cases  are  not  uncommon  where  a  small  tropical  abscess  with 
thick  organised  walls  has  existed  for  months,  or  even  years,  in 
a  quiescent  form,  and  has  then  undergone  enlargement  and 
burst.  Some  of  the  cases  met  with  in  this  country,  where  a 
large  abscess  forms  in  the  livers  of  persons  years  after  their 
return  from  India  admit  of  this  explanation  ;  while  others  are 
perhaps  what  Sir  James  Paget^  would  call '  residual  abscesses,'  or 
abscesses  formed  in  or  about  the  residues  of  former  inflammation. 

10.  The  circumstances  under  which  '  tropical  abscess '  occurs 
may  sometimes  be  of  material  assistance  in  diagnosis  : — 

a.  Its  frequency  in  certain  parts  of  the  tropics,  and  particu- 
larly in  India  and  China,  and  its  extreme  rarity  in  temperate 
climates,  except  in  persons  who  have  visited  tropical  countries. 
In  the  West  Indies,  curiously  enough,  it  is  comparatively  rare. 

h.  It  is  chiefly  met  with  between  the  ages  of  20  and  45. 

c.  It  is  most  common  in  persons  of  indolent  habits,  and  who 
have  been  excessive  eaters  or  intemperate  in  the  use  of  alcohol. 
Of  40  cases  in  which  the  habits  were  noted  by  Waring,  6 7 '5  per 
cent,  were  intemperate. 

d.  The  concurrence  of  dysentery. 

'  On  Residual  Abscesses,     St.  Earth.  Hosp.  Eep.  1869,  v.  73. 


I S6  ENLARGEMENTS    OF    THE    LIVER.  lect.  v. 

11.  The  diseases  most  likely  to  be  confounded  with  tropical 
abscess  are  hydatid  tumour,  inflammatory  enlargement  of  the 
gall-bladder,  pysemic  abscesses,  and  abscess  of  the  abdominal 
parietes  (see  p.  15). 

a.  A  hydatid  of  the  liver  is  the  enlargement  most  likely  to 
be  mistaken  for  abscess.  In  both  there  may  be  a  local  projec- 
tion from  the  general  contour  of  the  liver,  presenting  flluctuation 
and  occasionally  causing  bulging  of  the  ribs  or  a  semiglobular 
tumour  in  the  epigastrium.  Tropical  abscess  is  mainly  to  be 
distinguished  from  hydatid  by  the  presence  of  pain,  by  its  much 
more  rapid  course,  by  its  constitutional  symptoms,  and  by  the 
circumstances  under  which  it  occurs.  The  possibility,  however, 
already  referred  to,  of  a  hydatid  tumour  suppurating  or  becoming 
converted  into  an  abscess  must  not  be  lost  sight  of.  An  error 
in  diagnosis  from  this  cause  is  all  the  more  likely  to  arise  if  the 
patient,  as  often  happens,  has  been  ignorant  of  the  existence 
of  the  hydatid  tumour  prior  to  the  occurrence  of  the  acute 
symptoms  due  to  its  taking  on  inflammatory  action.  Any  doubt 
will  usually  be  removed  by  an  exploratory  puncture,  while  the 
treatment  in  both  cases  will  be  the  same. 

h.  The  circumstances  under  which  enlargement  of  the 
gall-bladder  may  simulate  hepatic  abscess  and  its  distinguishing 
characters  will  be  considered  in  a  subsequent  lecture.  It  niay 
be  here  observed,  however,  that  a  large  abscess  connected  with 
the  liver  in  a  person  who  has  never  left  this  country  is  in  most 
cases  either  a  suppurating  hydatid  or  an  inflamed  gall-bladder, 
c.  The  constitutional  symptoms  of  tropical  and  pynemic 
abscesses  may  be  identical.  For  distinguishing  them,  we  must 
rely  mainly  on  the  form  of  the  enlargement,  the  circum- 
stances under  which  each  occurs  (see  pp.  166  and  185),  and  the 
greater  tendency  in  the  pysemic  abscess  to  jaundice  and 
symptoms  of  blood-poisoning. 

Treatment. — A.  Before  suppuration.  Until  a  comparatively 
recent  date  the  two  remedial  measures  mainly  relied  on  in  the 
treatment  of  tropical  abscess  of  the  liver  were  general  blood- 
letting and  mercury.  With  regard  to  bloodletting  there  can  be 
no  doubt  that  in  the  case  of  plethoric  Europeans  but  recently 
arrived  in  the  tropics,  in  whom  the  disease  often  sets  in  acutely, 
with  full  firm  pulse  and  high  temperature,  it  often  relieved  pain 
and  reduced  the  fever,  but  there  is  no  evidence  that  it  prevented 
suppuration  and  some  suspicion  that  it  hastened  it,  while  all  its 
good  effects  will  be  obtained  by  the  application  of  a  few  leeches 


LKCT.  V.  TROPICAL    ABSCESS.  1 87 

over  tlie  liver  or  round  the  anus.  The  same  may  be  said  of 
mercury.  Pushed  to  salivation,  it  is  more  likely  to  favour 
suppuration  than  to  prevent  it,  and  it  will  certainly  increase  the 
tendency  to  malarial  cachexia  and  anaemia.  Except  as  an  occa- 
sional aperient,  it  ought  never  to  be  given.  The  rules  for  the 
treatment  of  the  early  stage  of  tropical  hepatitis  are  the  same 
as  those  which  I  laid  down  in  my  last  lecture  for  congestion  of 
the  liver  (p.  134),  the  remedies  on  which  reliance  is  mainly  to 
be  placed  being  the  chloride  of  ammonium  and  ipecacuanha  in 
large  doses.  The  liability  to  diarrhoea  or  dysentery  makes  it 
necessary  to  be  more  cautious  in  the  use  of  purgatives  than  in 
the  ordinary  hepatic  congestions  of  this  country. 

B.  After  suppuration.  In  tropical  abscess  of  the  liver,  not 
only  may  we  hope  to  prevent  suppuration  by  appropriate  treat- 
ment, but  even  after  it  has  occurred  the  case  is  far  from 
being,  as  in  the  pysemic  abscess,  necessarily  fatal.  The  treat- 
ment, however,  for  the  stage  antecedent  to  suppuration  is  no 
longer  suitable. 

1.  Warm  fomentations  and  poultices  are  still  to  be  applied 
to  the  region  of  the  liver ;  and  in  the  event  of  acute  pain  super- 
vening, although  this  usually  indicates  an  advanced  stage  of 
the  disease,  a  few  leeches  will  often  give  relief. 

2.  The  patient's  strength  must  be  supported  by  mineral 
acids  and  vegetable  tonics,  and  in  particular  by  the  sulphuric 
or  nitric  acid  with  quinine. 

3.  Opium  is  in  most  cases  necessary  to  relieve  pain,  to 
procure  sleep,  or  to  allay  the  harassing  cough. 

4.  Purgatives  are  no  longer  called  for.  If  the  bowels  be 
constipated,  a  mild  laxative  may  be  given  from  time  to  time,  but 
more  commonly  there  is  diarrhoea  or  dysentery,  necessitating 
the  use  of  vegetable  and  mineral  astringents,  with  opiate 
enemata  or  suppositories. 

5.  The  diet  must  be  of  a  more  generous  nature  than  that 
which  is  permissible  in  the  stage  of  congestion  ;  and  when  the 
circulation  is  weak,  small  quantities  of  wine  or  brandy  will  be 
necessary. 

6.  In  multiple  abscesses,  which  must  be  regarded  as  a  local 
manifestation  of  a  general  disease,  it  is  clear  that  no  advantage 
is  to  be  derived  from  operative  interference,  but  when  there  is 
a  single  large  abscess,  the  general  symptoms  being  here  the 
result  of  the  local  disease,  the  propriety  of  evacuating  the  pus 
may  fairly  be  entertained.     It  is  no  doubt  true  that  a  large 


1 88  ENLARGEMENTS    OP    THE    LIVER,  lect.  V. 

abscess  of  the  liver  may  become  encysted  and  shrivel  up,  and  in 
this  way  undergo  what  may  be  called  a  spontaneous  cure,  in- 
dependently of  rupture,  but  this  is  an  event  so  rare  that  it 
cannot  be  calculated  on.  Eecovery  also  takes  place  occa- 
sionally in  consequence  of  the  abscess  emptying  itself  through 
a  bronchial  tube,  into  the  bowel,  or  externally  through  the 
abdominal  parietes  ;  but  the  process  is  tedious,  and  even  when 
it  occurs  many  patients  die  of  exhaustion  from  fever,  pneumo- 
nia, or  diarrhoea,  to  say  nothing  of  their  liability  to  destruction 
at  any  moment  from  the  abscess  bursting  into  the  pericardium, 
the  pleura,  or  the  peritoneum.  In  a  large  proportion  of  cases, 
however,  the  patient  dies  while  the  abscess  is  still  confined  to 
the  liver.  ^  Under  these  circumstances  the  expedienc}""  of  hasten- 
ing the  evacuation  of  the  matter  naturally  suggests  itself. 

You  will  find  nevertheless  that  professional  opinion  is 
divided  on  this  important  question.  Dr.  Budd,  in  his  standaid 
work  on  '  Diseases  of  the  Liver,'  considers  the  dangers  of 
operating  so  many  and  so  great,  that  it  is  better  to  let  matters 
alone  and  allow  the  abscess  to  open  of  itself.^  Some  authorities, 
again,  such  as  Frerichs^  and  Morehead,'*  advocate  opening  the 
abscess  in  selected  cases ;  while  others,  like  Dr.  Murray,  for- 
merly Inspector-General  of  Hospitals  in  Bengal,  Dr.  Cameron,^ 
and  Sir  Ranald  Martin,*'  maintain  that  '  when  we  have  just 
grounds  for  believing  that  abscess  of  the  liver  exists,  we  ought 
not  to  lose  a  day  in  evacuating  it  by  puncture,  and  that  we  are 
both  justified  and  safe  in  endeavouring  to  hit  upon  it  with  a 
trocar  when  deep-seated,  avoiding  the  gall-bladder  and  large 
veins.' ^  Dr.  Cameron,  in  fact,  goes  so  far  as  to  recommend 
exploring  the  liver  with  a  trocar  in  cases  where  the  existence 
of  an  abscess  is  suspected,  though  not  certain,  and  has  published 
cases  where  no  pus  was  found,  and  yet  the  patient's  symptoms 
subsided,  instead  of  being  aggravated,  subsequently  to  the  ex- 
ploration.    Amid  such  conflicting  opinions  we  may  be  aided  in 

'  Of  300  fatal  cases  of  licpatic  absi'css  collected  by  Mr.  Waring,  the  aljscess,  at 
the  time  of  death,  had  not  extended  beyond  the  boundaries  of  the  liver  in  169  ;  in  48 
it  had  been  opened  by  operation  ;  in  42  it  had  opened  spontaneously  into  the  rigiit 
lung  or  thoracic  cavity  ;  in  15,  into  the  peritoneum  ;  in  S,  into  the  stomach  or  colon  ; 
in  3,  intfj  the  hepatic  vein,  &e.     Op.  cit. 

«  Op.  cit.  3rd  ed.  ISoZ,  p.  124. 

'  Dis.  of  Liver,  Syd.  Soc.  Kd.  ii.  p.  147. 

<  Kes.  on  Dis.  in  India,  2nd  cd.  18G0,  p.  410. 

»  Lancet,  Juno  6  and  13,  Aug.  8,  1863. 

•  Lancet,  Aug.  20  and  27,  1804. 

'  Cameron.     Liincet,  June  G,  1863,  p.  631. 


IKCT.  V.  TEOPICAL    ABSCESS.  1 89 

forming-  a  just  judgment  by  considering,  on  the  one  hand,  the 
dangers  of  the  operation,  and,  on  the  other,  the  dangers  of  non- 
interference. 

The  main  objections  raised  against  the  operation  are  as 
follows : — 

a.  That  pus  is  apt  to  escape  into  the  peritoneum  and  excite 
fatal  peritonitis.  In  most  cases,  however,  when  the  abscess  is 
near  the  surface,  there  would  be  adhesions  which  would  pre- 
vent the  entrance  of  pus  into  the  peritoneum.  Morehead  speaks 
of  the  absence  of  adhesions  as  quite  exceptional  (in  only  3  of  76 
fatal  cases).  Moreover,  if  desirable,  it  is  always  possible  to 
produce  adhesions. 

h.  That  air  will  enter  the  abscess  and  excite  fresh  inflam- 
mation, or  pyaemia.  This  is  an  undoubted  source  of  danger ; 
but  it  is  as  likely  to  be  incurred  if  the  abscess  opens  spon- 
taneously into  the  bowel,  a  bronchial  tube,  or  externally.  More- 
over, it  may  be  in  a  great  measure  prevented  by  the  use  of 
antiseptics. 

c.  That  the  mechanical  injury  of  the  puncture  is  apt  to 
produce  haemorrhage  and  fresh  inflammation  in  the  hepatic 
tissue.  So  far  as  I  have  been  able  to  ascertain,  this  is  an  ob- 
jection founded  on  theoretical  considerations  rather  than  on 
actual  observation.  I  have  had  several  opportunities  of  con- 
firming Dr.  Cameron's  statement  to  the  effect  that  a  fine  trocar 
can  be  plunged  into  the  liver  without  any  ill  result,  and  with- 
out, in  fact,  any  trace  of  the  puncture  being  discernible  when 
death  occurs  shortly  afterwards  (see  Case  LXXXII.). 

d.  That  the  fatal  event  may  be  hastened  by  gangrene  of  the 
tissues  arcund  the  wound  spreading  inwards  to  the  liver.'  This 
accident  has  been  chiefly  observed  when  the  opening  has  been 
made  in  an  intercostal  space,  and  then,  as  Morehead  has  shown, 
it  occurs  alike  when  a  spontaneous  rupture  takes  place,  and 
when  a  puncture  is  made.^  The  gangrene  is  most  probably 
connected  with  the  caries  or  necrosis  of  the  ribs,  which  is 
almost  always  present  in  these  cases,  and  which  would  probably 
not  occur  were  the  abscess  opened  before  the  ribs  became 
implicated.  This  danger  might  also  be  averted  by  opening 
from  below  the  ribs  and  by  the  use  of  antiseptics. 

The  chief  dangers  of  non-interference  are  these  : — 
a.  The  abscess  daily  becomes  larger,  more  and  more  of  the 
hepatic  tissue  is  destroyed,  and  ultimately  the  gland  may  be 

'  Maclean.     Lancet,  July  18,  1863.  ^  Op.  cit.  p.  410. 


1 90  ENLARGEMENTS    OF   THE    LIVER.  lect.  v. 

reduced  to  a  mere  sac  containing  pus,  while  adjacent  organs 
are  compressed  and  the  ribs  are  eroded. 

h.  The  patient  may  die  suddenly  from  the  abscess  bursting 
into  the  pericardium,  the  peritoneum,  or  the  pleura.  Not  long 
ago  I  saw  a  patient  with  abscess  of  the  liver  beginning  to  point 
at  the  epigastrium.  I  advised  paracentesis,  but  as  the  case 
was  not  considered  urgent  this  was  delayed.  Two  days  after- 
wards the  gentleman  died  quite  suddenly.  The  abscess,  in 
process  of  opening  into  the  colon,  had  leaked  into  the  peri- 
toneum. 

c.  The  majority  of  patients  with  abscess  of  the  liver  die  of 
exhaustion  from  hectic  fever  or  diarrhoea,  either  while  the 
abscess  is  still  confined  to  the  liver,  or  after  it  has  burst. 

Statistics  have  been  appealed  to  with  the  object  of  proving 
the  uselessness  of  operative  interference.  Of  81  cases  where 
the  abscess  was  opened,  collected  by  Mr.  Waring,  only  15  (or 
18-5  per  cent.)  recovered,  and  of  24  cases  recorded  by  Morehead, 
only  8,  or  one-third,  recovered.  But  in  many  of  these  cases 
death  was  due,  not  to  the  operation,  but  probably  to  this 
having  been  too  long  delayed,  or  to  proper  precautions  not 
having  been  adopted  ;  while  several  of  Waring's  cases  were 
examples  of  multiple  abscesses,  for  which  an  operation  was  ob- 
viously unsuited.  Moreover,  of  203  cases  collected  by  Rouis, 
where  the  abscess  was  not  opened,  162  (or  80  per  cent.)  died.' 

After  duly  balancing,  then,  the  dangers  of  operation  against 
the  dangers  of  expectancy,  I  do  not  hesitate  to  recommend  to 
you  the  propriety  of  evacuating  the  pus,  with  proper  precau- 
tions, in  a  large  number  of  cases  of  tropical  abscess  of  the  liver. 
The  operation  may  not  be  free  from  danger,  but  to  wait  in  these 
cases  upon  Nature,  as  it  is  called,  is  to  wait  upon  Death,  and  I 
would  suggest  for  your  guidance  the  following  rules  : — 

a.  In  all  cases  where  there  is  a  visible  fluctuating  tumour, 
operate  at  once. 

h.  In  cases  where  the  symptoms  of  abscess  of  the  liver  are 
present,  with  a  distinct  tumour  projecting  from  the  normal 
contour  of  the  liver,  or  causing  bulging  of  the  ribs,  though 
there  be  no  perceptible  fluctuation,  it  will  be  well  to  operate. 

c.  When  symptoms  of  abscess  coexist  with  uniform  enlarge- 
ment of  the  liver,  but  with  no  distinct  tumour  or  bulging,  if 
there  be  any  local  oedema,  or  obliteration  of  an  intercostal  space, 

'  Frerichs,  op.  cit.  ii.p.  136. 


TROPICAL    ABSCESS. 


191 


or  pain  localised  to  one  spot  when  pressure  is  made  on  it,  or  when 
the  patient  takes  a  fall  inspiration,  it  will  be  well  to  operate. 

d.  Where  there  are  no  local  signs  of  abscess,  but  where  the 
constitutional  symptoms  leave  little  doubt  of  its  existence,  and 
are  severe,  one  or  more  exploratory  punctures  with  the  aspirator 
will  be  advisable  (see  Case  LXXXII.).  Even  if  the  abscess  be 
not  reached,  the  direct  abstraction  of  a  small  quantity  of  blood 
from  the  liver  sometimes  gives  great  relief. 

e.  When  from  the  presence  of  jaundice  or  other  symptoms 
there  is  reason  to  fear  that  there  are  numerous  abscesses,  it  will 
be  better  to  abstain  from  any  operation. 

When  the  operation  is  resolved  on,  it  may  be  performed  as 
follows — 

a.  When  there  is  distinct  pointing  with  an  inflammatory 
blush  of  the  skin,  and  the  abscess  is  small,  an  opening  may  be 
made  with  a  bistoury. 

h.  Under  other  circumstances  a  small  trocar  will  be  pre- 
ferable, and  it  ought  to  be  introduced  wherever  there  is  the 
slightest  fulness,  superficial  oedema,  or  tenderness. 

c.  When  the  abscess  is  small,  not  holding  more  than  ten  or 
twelve  ounces,  it  may  be  completely  evacuated,  and  a  drainage- 
tube  fastened  in  for  some  days.  On  the  removal  of  the  tube,  a 
tent  of  lint  dipped  in  carbolic  oil  may  be  substituted. 

d.  In  all  cases  where  an  external  opening  is  made  the 
antiseptic  measures  recommended  by  Professor  Lister  ouo-ht  to 
be  rigidly  enforced,  and  when  the  abscess  is  very  large,  reco- 
very will  sometimes  be  hastened  by  making  a  counter-openino" 
and  passing  a  drainage-tube  through  both  openings. 

e.  When  the  abscess  is  very  large,  it  will  be  better  to  evacuate 
it  by  instalments  at  short  intervals,  carefully  excluding  the  air 
on  each  occasion.  For  this  purpose  Bowditch's  syringe  or 
Dieulafoy's  aspirator  are  well  adapted.' 

/.  In  the  exceptional  cases  where  no  adhesions  exist,  it  will 
be  prudent  to  produce  them  by  the  local  application  of  caustic 
potash  before  puncturing,  but  when  the  puncture  is  made  in 
an  intercostal  space  this  proceeding  is  unnecessary. 

The  first  of  the  following  cases  is  an  excellent  illustration 
of  tropical  abscess  of  the  liver  independent  of  dysentery,  not- 

'  The  reader  is  referred  to  an  interesting  case  recorded  hy  Professor  Maclean,  C.B. 
where  recovery  followed  the  removal  of  108  ounces  of  pns  by  the  aspirator.  Lancet 
1873,  ii.  39. 


192  ENLARGEMENTS    OF   THE    LIVER.  lect.  v, 

withstanding  that  after  the  formation  of  pus  diarrhoea  was  a 
prominent  symptom.  It  is  a  matter  of  regret  that  the  abscess 
was  not  punctured ;  but  twenty-three  years  ago  this  operation 
was  rarely  practised. 

Case  LXXIV. — Tropical  Ahscess  of  Liver — No  Dysenteric  Ulceration 

of  Boivel. 

Private  H.  C ,  aged  33,  of  the  2nd  European  Bengal  Fusileers, 

was  admitted  under  my  care  into  the  Military  Hospital  at  Prome,  on 
Nov.  12,  1853.  His  habits  had  been  very  dissipated  ;  he  had  suffered 
from  many  attacks  of  fever  and  congestion  of  liver,  and  shortly  before 
his  admission  he  had  been  exposed  almost  continuously  for  three  weeks 
to  wet  on  the  decks  of  steamers,  during  passage  from  Calcutta  to  Ran- 
goon and  from  Rangoon  up  the  Irrawaddi  to  Prome.  He  had  never 
had  dysentery.  He  began  to  suffer  from  fever  and  pain  in  right  side 
in  first  week  of  October  during  passage  from  Calcutta,  but  his  condi- 
tion f1id  not  prevent  bim  attending  to  his  duty  until  a  few  days  before 
admission,  when  pain  in  side  became  much  more  severe. 

On  admission,  pulse  112  ;  skin  hot.  Much  pain  in  region  of  liver, 
and  stretching  up  to  right  shoulder ;  pain  was  greatly  increased  by 
coughing  or  taking  a  long  breath,  and  there  was  considerable  tencicr- 
ncss  on  pressure  over  epigastrium  and  below  right  ribs.  Hepatic  dul- 
ness  in  r.  m.  1.  measured  6  inches.  Posteriorly  and  upwards  margins  of 
liepatic  dulness  were  normal,  and  the  increased  size  appeared  due  to  a 
bulging  from  the  lower  margin.  No  fluctuation  and  no  jaundice  or 
ascites,  but  there  was  less  movement  of  ribs  in  respiration  on  right 
side  than  on  left,  and  frequent  cough.  Tongue  moist  and  coated  white; 
frequent  vomiting ;  a  day  or  two  before  admission  bowels  had  been 
relaxed,  but  at  time  of  admission  they  were  costive.  Some  scalding  in 
micturition;  urine  was  high-coloured;  sp.  gr.  1027;  it  contained  no 
albumen,  but  deposited  crystals  of  lithic  acid. 

Patient  was  cupped  to  8  oz.  over  liver,  and  during  first  week 
after  admission  was  treated  with  calomel  and  opium,  and  subsequently 
with  nitro-muriatic  acid,  quinine,  opiates,  and  wine. 

On  Nov.  18  diarrhoea  came  on,  with  profuse  night-sweats,  but  no 
rigors.  Vomiting  continued,  and  tongue  was  clean,  very  red,  and 
deeply  fissured.  Cough  and  scalding  in  micturition  had  abated,  but 
vomiting  and  diarrhoea  persisted,  notwithstanding  use  of  remedies. 
On  Nov.  20  tongue  dry  and  brown.  Patient  became  very  emaciated, 
but  was  comjiaratively  free  from  pain  until  Nov.  2G,  when  he  was 
seized  Avitli  acute  pain,  shooting  up  from  region  of  liver  to  right  shoul- 
der. On  following  day  this  had  subsided  ;  and  after  this  there  was  but 
little  vomiting  or  purging,  and  symptoms  Avere  mainly  those  of  hectic 
fever,  with  increasing  prostration,  until  Dec.  1,  when  there  was  noticed 
below  right  ribs,  rather  to  right  of  mammary  line,   a  distinct  smooth 


LECT.  T.  TEOPICAL   ABSCESS.  I93 

rounded  bulging,  with  obscure  fluctuation  in  centre.  Hepatic  dulne.ss 
in  riglit  mammary  line  was  now  8  in.,  increase  being  due  to  a  pro- 
jection downwards  from  lower  margin  of  normal  area  of  hepatic  dul- 
ness.  There  was  also  considerable  bulging  of  lower  right  ribs.  Pa- 
tient was  now  free  from  pain  ;  vomiting  and  purging  had  ceased ;  but 


Fig.  17  represents  the  outline  of  Hepatic  Dulness,  and  the  bulging  of  the  ribs  (a)  in 
H.  C. — — ,  on  December  2,  1853. 

cheeks  were  sunken  and  presented  a  hectic  flush,  fever  and  night- 
sweats  continued,  tongue  was  dry  and  brown,  and  teeth  coated  with 
sordes.  On  Dec.  8  patient  was  in  a  state  of  extreme  prostration  ;  on 
following  day  mind  was  wandering,  and  at  9.30  p.m.  he  died. 

On  examination  of  body  ten  hours  after  death,  one  enormous 
abscess  was  found  in  right  lobe  of  liver.  It  contained  upwards  of  four 
quarts  of  pus,  having  a  reddish  tint,  and  composed  of  pus-corpuscles, 
with  oil-globules  and  hepatic  cells  undergoing  disintegration.  Walls 
of  abscess  were  formed  by  ragged  masses  of  hepatic  tissue  coated  with 
inflammatory  products  ;  at  two  places  walls  were  very  thin,  one  situated 
below  margin  of  right  ribs,  and  corresponding  to  tumour  observed 
during  life,  and  the  other  posteriorly  near  mesial  fissure.  Stomach 
and  intestines  presented  no  trace  of  cicatrices  or  of  recent  ulceration. 
Spleen,  lungs,  and  heart  normal.  Old  adhesions  between  apposed 
surfaces  of  left  pleura ;  and  cavities  of  heart,  but  particularly  right, 
contained  large  masses  of  decolorised  fibrin. 

Case  LXXV.  is  another  example  of  tropical  abscess  inde- 
pendent of  dysentery.  Death  was  due  to  the  supervention  of 
pyaemia  and  secondary  abscesses  upon  the  opening.     The  good 

o 


194  ENLARGEMENTS    OF    THE    LIVER.  zf.ct.  v. 

effects  which  immediately  followed  the  operation  make  one 
regret  that  the  matter  was  not  drawn  off  by  instalments  with  a 
fine  trocar,  and  that  more  thoroughly  antiseptic  measures 
were  not  adopted. 


Case  LXXV. — Tropical  Abscess  of  Liver  independent  of  Dj/sentenj — 
Free  Opening — Secondary  Abscesses  and  Diarrhoea — Death  by 
Exhaustion. 

Foogeek  Kitche,  aged  39,  a  Japanese  juggler,  adm.  into  Middlesex 
Hosp.  Jan.  5,  1871.  Left  Japan  16  months  before  and  went  to  Madras, 
where  he  remained  a  month  and  drank  much  gin.  Never  had  dysen- 
tery and  had  always  enjoyed  good  health  until  three  months  after 
reaching  this  country  in  July  1870.  He  then  began  to  suffer  from 
weakness,  loss  of  appetite,  perspirations  during  sleep,  and  occasional 
pain  in  right  side,  and  since  then  he  had  lost  flesh.  One  month  before 
admission  he  was  obliged  to  give  up  work,  and  at  this  time  he  first 
noticed  a  swelling  below  right  ribs,  which  had  increased  considerably. 

On  admission  was  emaciated  and  complained  of  pain  and  swelling 
in  right  side.  In  epigastrium  and  right  hypochondrium  was  a  tumour 
projecting  from  liver  about  size  of  a  cocoanut,  causing  slight  aversion 
of  lower  right  ribs,  dull  on  percussion,  smooth,  very  elastic  but  yield- 
ing no  vibration,  and  but  slightly  tender  even  on  free  manipulation. 
Hepatic  dulness  in  r.  m.  1.,  including  tumour,  6^  in. ;  posteriori}'  liver 
did  not  rise  above  normal  level.  Tongue  moist  and  furred  ;  moderate 
appetite,  and  no  retching ;  considerable  thirst ;  no  jaundice  ;  bowels 
regular.  Pulse  80  ;  heart  and  lungs  normal.  Temp.  101^°  ;  still  per- 
spires during  sleep.  Urine  1030,  loaded  with  lithates,  but  free  from 
albumen.     Was  ordered  quinine  and  nitric  acid. 

Jan.  9. — Is  weaker,  and  has  had  more  pain  in  tumour,  which  is 
larger.  Has  required  morphia  to  make  him  sleep.  No  rigors,  but 
still  perspires  profusely  at  night.  Pulse  has  varied  from  68  to  84 ; 
and  temp,  from  99°  in  morning  to  103°  at  night.  After  a  preliminary 
exploratory  puncture  a  large  trocar  was  introduced  into  tumour,  and 
30  oz.  of  thick  ])ns  of  a  brick-red  colour  let  out.  Cavity  was  washed 
out  with  a  solution  of  chloride  of  zinc  (gr.  x  ad  |j),  and  cannula  was 
left  in  and  covered  with  lint  soaked  in  carbolic  oil  and  with  carded 
oakum. 

Jan.  13. — Operation  was  followed  by  great  relief.  Patient  slept 
without  morphia,  had  no  night-sweats,  and  temperature  became  normal 
in  evening  as  well  as  morning.  List  night,  however,  sweating  returned, 
and  to-day  pulse  96  and  temp.  1003°  ;  very  little  discharge.  On  with- 
drawing cannula  10  oz.  of  pus,  not  fetid,  escaped.  Cavity  was  again 
washed  out  with  a  solution  of  chloride  of  zinc,  and  a  piece  of  elastic 
tube  was  substituted  for  cannula. 


TEOPICAL    ABSCESS. 


1^5 


Jan.  20. — During  last  week  patient,  thougli  weak,  has  felt  much 
better.  There  has  been  very  free  discharge  from  opening  ;  pulse  has 
varied  from  60  to  84,  and  temp,  has  never  been  above  normal.  Appe- 
tite has  been  excellent,  and  for  last  three  days  patient  has  had  meat, 
eggs,  and  porter.  To-day,  for  first  time,  discharge  has  been  slightly 
oflFensive,  and  patient  does  not  feel  quite  so  well.  Porter  was  discon- 
tinued, and  cavity  was  ordered  to  be  washed  out  daily  with  a  weak 
solution  of  carboKc  acid. 

Jan,  27. — Is  weaker,  but  appetite  has  continued  good  ;  has  had  no 
rigor,  very  little  perspiration,  and  free  discharge,  not  fetid,  from  wound. 
Temp,  has  been  normal,  except  for  a  few  hours  on  Jan.  21,  when  it  rose 
to  101°.  On  Jan.  23  he  had  four  loose  stools,  and  since  Jan.  24  there 
has  been  a  troublesome  cough.  Yesterday  evening,  on  commencing  to 
syringe  out  cavity,  patient  was  seized  with  severe  pain  in  hepatic  re- 
gion and  profuse  perspiration,  which  lasted  an  hour.  Only  a  very  little 
reddish  matter  came  away,  but  this  morning  discharge  is  free  and 
deeply  tinged  with  bile.  Pulse  64  ;  temp.  96 "8°.  Indiarubber  tube 
was  withdrawn,  and  a  piece  of  lint  soaked  in  carbolic  oil  inserted  in 
wound  instead. 

Feb.  1. — Very  little  discharge  has  come  away  from  wound,  and  on 
Jan.  29  little  that  came  was  fetid,  but  to-day  discharge  is  more  co- 
pious. Patient  has  occasionally  complained  of  rather  severe  pain  in 
region  of  liver,  and  night-sweats  have  returned.  ISTo  rigors,  and  temp, 
has  always  been  normal  until  to-day,  when  it  is  101°.  Bowels  are  re- 
laxed, and  patient  is  getting  much  thinner. 

Patient  nowbecame  rapidly  weaker.  N^ight-sweats  and  diarrhoea 
were  uncontrolled  by  treatment.  Temp,  varied  from  99°  to  102*8°, 
but  at  no  time  were  rigors  noted,  and  pulse  was  usually  120 ;  urine 
free  from  albumen.     Death  took  place  on  Feb.  4. 

Autopsy. — Right  lobe  of  liver  was  glued  by  soft  adhesions  to  abdo- 
minal parietes  over  a  space  about  3^  in.  in  diameter,  and  was  more 
firmly  connected  to  diaphragm  above  and  behind  where  abscess  came 
close  to  surface  ;  but  greater  part  of  surface  of  liver  presented  no  sign 
of  inflammation,  old  or  recent.  Sac  of  abscess  had  evidently  con- 
tracted, for  it  would  not  have  held  more  than  16  oz.  of  fluid.  Its  walls 
were  very  thick,  and  composed  of  an  external  firm  fibrous  layer  several 
lines  in  thickness,  and  of  an  internal  lining  of  softer  honeycombed 
material.  In  remaining  portion  of  liver  were  several  abscesses  from. 
size  of  cherry  to  that  of  walnut,  with  no  thickened  walls  and  evidently 
quite  recent.  Base  of  right  lung  was  glued  to  diaphragm  by  soft 
lymph,  and  right  pleura  contained  about  an  ounce  of  flaky  fluid. 
Spleen  healthy  ;  kidneys  congested  ;  large  intestine  presented  no  trace 
of  cicatrices,  thickening,  or  other  sign  of  old  dysentery  ;  but  in  csecuna 
and  ascending  colon  mucous  membrane  was  intensely  injected,  and 
rugae  were  plastered  with  large  flakes  of  granular  exudation,  two 
small  patches  of  which  were  also  found  in  ilium  just  above  valve. 

o  2 


in6  EKLAEGEMENTS    OF    THE    LIVER.  i-ect.  v. 

In  Case  LXX^H!.  the  abscess  discharged  itself  through  the 
right  lung,  and  the  patient  made  a  rapid  recovery.  It  is  a 
good  illustration  of  the  most  favourable  direction  that  the 
abscess  can  take. 

Case  LXXVI. — Abscess  of  Liver  discharging  through  right  Lung — 

RHCOvery. 

On  May  2,  1874,  I  was  consulted  by  Dr.  L.,  about  35.  Eight 
■weeks  before  he  had  returned  from  Gold  Coast,  where  he  had  .suffered 
from  fever  and  pain  in  right  side.  On  reaching  this  country  he  had 
felt  quite  well,  and  had  gone  about.  Three  weeks  after  arrival  he  had 
got  a  rigor  one  night  after  going  to  theatre,  and  ever  since  he  had 
been  laid  up  with  fever.  Temperature  had  been  as  high  as  105°.  At  first 
there  had  been  considerable  delirium,  and  latterly  profuse  night-sweats, 
but  no  return  of  rigors.  At  my  visit  great  prostration ;  pulse  108  ; 
temp.  102° ;  resp.  48.  Hepatic  dulness  reached  up  to  right  nipple  ; 
it  did  not  come  too  low,  but  there  was  distinct  bulging  of  right  lower 
costal  cartilages.  Frequent  dry  cough  ;  crepitation  at  base  of  both 
lungs ;  and  sharp  stitch  in  right  side.  Tongue  thickly  coated  vnth 
yellow  fur  ;  bowels  confined,  and  had  been  so  throughout ;  urine  dark, 
and  loaded  with  lithates. 

Ordered  ammon.  chlor.  gr.  xx,  pot.  bicarb,  gr.  xv,  and  tinct. 
op.  v\  V,  every  six  hours  ;  colocynth  and  calomel  pills.  Quin.  sulph. 
gr.  X  while  perspiring.     Milk,  beef-tea,  and  claret. 

On  morning  of  May  6  he  suddenly  began  to  cough  up  pus  of  a 
reddish-brown  colour  and  mawkish  smell,  and  in  next  24  hours  brought 
up  about  two  pints.  Breath  had  odour  similar  to  that  of  pns.  A 
mixture  of  quinine  and  mineral  acids  was  now  substituted  for  chloride 
of  ammonium  &c. 

Almost  immediately  after  bursting  of  abscess  into  king  there  was 
a  fall  in  pulse,  temperature,  and  respirations  ;  night-sweats  diminished 
and  general  condition  improved.  Expectoration  of  pus  continued  for 
about  ten  days.  On  May  11  temp,  rose  for  a  few  hours  to  104°,  but 
after  this  it  was  normal ;  and  on  June  2  patient  had  so  far  recovered 
that  he  was  able  to  go  to  Scotland.  He  had  no  relapse,  and  16  months 
afterwards  (Sept.  25,  1876)  he  was  well  and  stout,  and  on  examination, 
no  trace  of  former  illness  could  be  discovered,  except  sliglit  impair- 
ment of  breath  sound  at  base  of  right  lung.     Oct.  1876  ;  still  well. 

In  Case  LXXVII.  the  abscess  also  burst  upwards  through 
the  diaphragm,  but  the  result  was  fatal. 

Case  LXXVII. — Abscess  of  Liver  opening  upwards  through  Diaphragm 
— Secondary  Abscess  of  Lung. 

I  show  you  here  a  specimen  which  I  removed  some  years  ago  from 
the  body  of  a  patient — a  man,  aged  34,  who  died  in  this   (Middlesex) 


LECT.  V  TEOPICAL    ABSCESS.  I97 

liospital — and  which  illustrates  the  bursting  of  a  large  abscess  upwards 
through  the  diaphragm.  In  this  case  patient  had  suffered  some  years 
before  from  dysentery  in  India  arid  Malta.  His  symptoms  during  the 
nine  days  that  he  was  in  hospital  before  his  death  were  hectic  fever  and 
emaciation,  dyspnosa,  cough,  and  purulent  expectoration,  with  a  pain- 
ful enlargement  of  liver  producing  an  outward  bulging  of  ribs. 
Hepatic  dulness  extended  only  2  in.  below  margin  of  ribs  in  r.  m.  1., 
but  upwards  it  reached  to  third  intercostal  space.  The  enlargement 
felt  smooth,  but  did  not  involve  whole  organ  uniformly.  Tongue  un- 
usually red  ;  no  vomiting,  jaundice,  or  diarrhoea,  but  abdomen  generally 
tender,  and  distinct  evidence  of  fluid  in  peritoneum. 

After  death,  three  or  four  pints  of  flaky  serum  were  found  in  peri- 
toneum. Liver  firmly  adherent  to  diaphragm  and  abdominal  parietes, 
and  in  upper  part  of  right  lobe  was  an  abscess  as  large  as  a  cocoanut, 
which  had  perforated  diaphragm  so  as  to  be  bounded  above  by  base  of 
right  lung.  The  abscess  was  enclosed  in  a  dense  capsule  of  areolar 
tissue,  and  contained  yellow  pus  with  large  fibrinous  flakes.  In  lower 
lobe  of  right  lung  was  another  abscess,  the  size  of  a  large  orange,  dis- 
tinct from  former,  and  containing  pinkish  pus.  Descending  colon  and 
sigmoid  flexure  much  contracted  ;  their  coats  thickened  ;  mucous  mem- 
brane slate-coloured,  but  presented  no  recent  ulcers  or  distinct  cica- 
trices. 

Ill  the  two  following  cases  the  abscess  opened  into  the 
bowel — probably  the  colon ;  but  there  was  a  subsequent  history 
of  refilling  of  the  cavity  and  discharge  on  repeated  occasions. 
I  do  not  remember  having  seen  this  occurrence  referred  to  by 
authors,  but  from  my  experience  I  am  inclined  to  think  that  it 
is  a  not  uncommon  sequel  of  the  bursting  of  a  large  hepatic 
abscess  into  the  bowel.  Of  nine  cases  where  the  abscess  seemed 
to  open  into  the  bowel,  and  of  which  I  have  notes,  there  was  a 
similar  history  in  six ;  and  in  a  tenth  case  the  abscess  opened 
first  into  the  bowel  and  then  into  the  lung. 

Case   LXXVIIE. — Abscess  of  Liver   opening   into   Bowel — Frequent 
refilling  of  Cavity  with  Pus.     Death  by  Diarrhcea  and  Exhaustion. 

On  May  25,  1871, 1  was  consulted  by  Mr.  K.,  aged  50,  on  his  return 
from  Ceylon,  where  he  had  been  for  25  years.  He  had  been  suffering 
for  nine  months  from  bilious  diarrhoea  and  occasional  vomiting.  He 
had  considerable  pain  about  the  liver,  which  was  somewhat  enlarged 
and  tender,  and  with  this  there  was  loss  of  appetite,  pyrexia,  night- 
sweats,  occasional  rigors,  prostration,  and  emaciation.  After  this  I 
saw  him  from  time  to  time  until  his  death  in  February  1875.  At  first 
he  improved  much  under  treatment,  but  on  April  9, 1872,  after  several 
weeks   of  great  agony  an  abscess  burst,  and  he  discharged  at  one. 


198  ENLARGEMENTS    OF    THE    LIVER.  lbct.  v. 

sitting  three  quarts  of  pus  from  the  bowels,  and  almost  a  like  quantity 
on  twelve  different  occasions  during  the  next  fortnight.  After  this  he 
was  nerer  well.  He  had  constant  diarrhoea.  But  now  and  then,  three 
or  four  times  in  course  of  the  year,  diarrhoea  would  stop  for  10  or  14 
days,  and  then  he  would  have  rigors,  pyrexia,  enlargement  and  pain  of 
liver,  all  of  these  symptoms  ceasing  with  a  free  discharge  qf  pus  from 
bowels.  On  one  occasion  after  rigors  and  pyrexia  he  vomited  several 
ounces  of  pus  and  blood.  The  tongue  and  mouth  at  last  became  red 
and  aphthous,  so  that  he  could  take  little  food,  and  death  from  exhaus- 
tion ended  his  sufferings.      There  was  no  post-mortem  examination. 


Case  LXXIX. — Tropical  Abscess  of  Liver  opening  into  Boivel — Frequent 
Relapses — Superficial  Foiriting — Free  Incision — Recovery . 

Mr.  N ,  aged  44,  was  sent  to  me  on  April  7,  1873,  by  Dr.   R. 

J.  Black,  of  Canonbury.  He  had  returned  on  14th  of  previous  No- 
vember from  China  and  Japan,  where  he  had  not  been  very  temperate. 
On  voyage  home,  when  at  Aden,  he  had  been  first  seized  with 
symptoms  of  acute  congestion  of  liver,  but  he  was  not  obliged  to  take  to 
bed  until  Dec.  20,  about  which  time  a  painful  swelling  appeared  below 
right  ribs,  and  he  suffered  from  rigors  and  night-sweats.  Swelling  con- 
tinued to  increase  until  beginning  of  Februaiy,  whenhedischargedalarge 
quantity  of  pus  by  bowel.  Swelling  subsided,  and  general  symptoms 
improved.  When  I  saw  him  he  was  thin  and  weak,  but  he  was  free 
from  pain  and  fever,  and  liver  was  not  enlarged. 

Three  or  four  days  after  seeing  me  he  was  again  seized  with  rigors 
and  pyrexia,  and  there  was  pain  in  hepatic  region  and  some  bulging  of 
right  costal  cartilages  and  epigastrium ;  and  when  I  saw  him  again  on 
April  22,  although  more  acute  symptoms  had  subsided,  bulging  per- 
sisted, and  he  perspired  much  during  sleep.  After  this  he  got  much 
better,  swelling  again  subsided,  and  for  a  fortnight  he  was  able  to  go  to 
business  in  City  ;  but  on  May  24  he  was  once  more  seized  Avith  rigors 
and  pyrexia,  followed  by  a  return  of  painful  swelling  in  same  situation 
as  before.  Swelling  increased  and  became  soft  and  fluctuating  in 
centre,  while  patient  had  profuse  night-sweats  and  grew  daily  thinner 
and  weaker. 

On  June  25  a  free  incision  was  made  by  Mr.  De  Morgan  into  swell- 
ing, and  nearly  two  pints  of  thick  pus  of  a  brick-red  colour  let  out. 
Cavity  was  washed  out  with  a  strong  solution  of  chloride  of  zinc 
(gr.  X  ad  ^j),  and  a  piece  of  elastic  tube  was  introduced  into  cavity 
and  secured  ;  and  through  this,  cavity  was  washed  out  daily  with  a 
weaker  solution  of  chloride  of  zinc  (gr.  iij  ad  |j)  :  end  of  tube  was 
covered  with  carded  oakum.  On  Juno  30  tube  was  removed  and 
wound  dressed  with  lint  and  carbolic  oil.  The  operation  gave  imme- 
diate relief;  fever  and  pain  at  once  ceased;  and  within  a  week  night- 
Hweats  had  also  ceased,  appetite  was  good,  and  patient   was  beginning 


LECT.  V.  TEOPICAL   ABSCESS.  1 99 

to  gain  flesh  and  strength.  He  had  several  relapses  of  fever  after  this, 
but  ultimately  he  made  a  good  recovery,  and  in  January  1875  he  was 
in  enjoyment  of  good  health  and  attending  to  business. 

Case  LXXX.  is  an  illustration  of  a  large  hepatic  abscess  in 
a  person  who  had  never  been  out  of  England,  although  there 
Mvere  doubts  at  the  time  whether  the  abscess  had  originated  in 
the  liver  or  in  the  areolar  tissue  about  the  kidney.  There  was 
ulceration  of  the  colon,  but  this  appeared  from  the  history  and 
post-mortem  appearances  to  be  secondary  to  the  abscess  of  the 
liver.  The  specimen  was  exhibited  by  me  to  the  Pathological 
Society,  and  the  case  is  recorded  in  the  eighth  volume  of  the 
'  Transactions.' 

Case  LXXX. — Large  Abscess  of  Liver  opening  into  Ascending  Colon. 

J.  P ,  a  man  aged  40,  was  admitted  into  St.  Mary's  Hospital, 

under  care  of  Dr.  Sibson,  on  April  18,  1856. 

He  stated  that  he  had  always  enjoyed  good  health  and  that,  although 
he  had  been  in  habit  of  drinking  a  good  deal  of  malt  liquor,  he  had 
never  been  addicted  to  spirits,  and  had,  on  the  whole,  been  a  temperate 
man.  He  had  never  been  abroad.  About  a  month  before  admission 
he  '  took  cold,'  and  was  seized  with  a  shooting  pain  in  right  hypochon- 
driac region,  which  on  second  day  became  so  extreme  as  to  prevent  his 
working.  He  went  to  bed,  where  he  remained  until  day  of  admission, 
pain  in  right  side'  continuing  without  intermission  except  when  relieved 
by  opium. 

After  admission,  there  was  found  to  be  a  great  fulness  in  right 
hypochondriac  and  lumbar  regions,  with  a  feeling  of  a  resisting  mass 
extending  downwards  as  far  as  crest  of  ilium,  and  forwards  to  within 
3  in.  of  linea  alba.  This  space  was  universally  dull  on  percussion,  and 
dulness  was  continuous  with  that  of  liver ;  upper  margin  of  hepatic 
dulness  was  not  elevated  and  dimensions  of  left  lobe  appeared  normal ; 
swelling  was  of  a  doughy  consistence,  and  presented  indistinct  fluctua- 
tion. Tongue  loaded  ;  bowels  rather  confined.  Urine  voided  three  or 
four  times  a  day,  and  acid  ;  sp.  gr.  1020.     Pulse  108,  weak. 

Poultices  of  linseed  meal  were  applied  over  swelling,  while  iodide 
of  potassium  (gr.  ij  ter  die),  gentle  laxatives,  opiates,  and  stimulants 
were  prescribed  internally. 

On  April  24  he  had  an  attack  of  erysipelas  of  face  which  continued 
for  four  or  five  days.  On  April  26,  during  this  erysipelas,  he  was 
seized  with  violent  diarrhoea.  This  ceased  in  a  great  measure  after 
four  or  five  days,  and  he  then  felt  himself  greatly  better  ;  appetite  had 
improved,  pain  had  gone,  swelling  and  dulness  were  much  diminished, 
and  calls  to  make  water  less  frequent.  He  continued  to  improve  until 
May  11,  on  which  day  he  had  a  return  of  severe   pain  and  diarrhoea, 


200  ENLAEGEMENTS    OF    THE    LIVEE.  XECT.  v. 

with  purulent  stools.  Pain  was  referred  chiefly  to  a  spot  about  two 
inches  below  margin  of  ribs,  in  a  line  with  right  nipple.  Stools  were 
of  a  light  bufi*  colour  and  very  offensive.  This  diarrhoea  resisted  all 
treatment,  and  soon,  patient's  strength  began  to  give  way.  He  had 
febrile  exacerbations  towards  evening,  and  profuse  perspirations  during 
night.  Pulse  varied  from  100  to  125,  and  was  very  weak  ;  tongue  be- 
came dry  and  brown  ;  and  he  gradually  sank  until  death  at  10  p.m.  on 
May  27.  Four  days  before  death  swelling  in  right  side  was  observed  to 
have  greatly  diminished,  dulness  in  right  lumbar  region  not  extending 
farther  forward  than  a  perpendicular  line  drawn  from  middle  of  Crest 
of  ilium  to  ribs. 

Post-mortem  examination  forty-one  hours  after  death. — On  opening 
abdomen,  extensive  adhesions  of  viscera  and  other  indications  of  peri- 
tonitis, entirely  limited  to  right  side,  peritoneum  on  left  side  being 
normal.  These  adhesions  of  viscera  on  right  side  rendered  their 
examination  extremely  difficult ;  whole  of  anterior  margin  of  right  lobe 
of  liver  firmly  adherent  to  peritoneal  surface  of  abdominal  wall,  while 
under  surface  of  anterior  edge,  along  with  gall-bladder,  was  in  intimate 
union  with  transverse  colon.  Texture  of  liver  was  pale.  In  lower 
part  of  right  lobe  was  an  abscess  as  large  as  two  fists,  containing  a 
quantity  of  fluid  feeculent  matter  of  a  light  yellow  colour.  This  abscess 
involved  almost  whole  of  that  portion  of  lobe  to  right  of  fissure  of 
gall-bladder,  and  extended  to  within  half  an  inch  of  its  upper  surface  ; 
upper  two-thirds  of  walls  of  abscess  formed  by  hepatic  tissue,  rough 
and  ragged  without  any  limiting  membrane  ;  lower  part  was  completed 
by  kidney,  anterior  layer  of  fascia  lumborum,  and  about  3  in.  of 
ascending  and  transverse  colon.  This  portion  of  colon  communicated 
freely  with  cavity  of  abscess.  Its  upper  wall  next  abscess  presented  a 
cribriform  appearance,  all  that  remained  of  it  being  a  few  narrow  bridles, 
passing  transversely  and  easily  torn  across.  Extensive  ulceration 
of  adjacent  portion  of  ascending  colon,  and  slight  ulceration  of  Peyer's 
patches  in  ileum.  Kidneys  anaemic,  spleen  soft  and  friable.  Thoracic 
organs  healthy,  left  cavities  of  heart  containing  blood,  right  being  empty. 

The  next  case  whicli  I  shall  mention  is  a  good  illustration 
of  the  benefit  which  may  often  be  derived  from  evacuation  of 
the  abscess. 


Case  LXXXI. — Tropical  Abscess  of  Liver — Puncture  with  a  large 
Trocar — Becovery. 

Mr.  C.  D ,  aged  23,  consulted  me  on  Juno  11,  18G7.     He  had 

arrived  from  Calcutta  the  day  before,  and  gave  the  following  account 
of  himself.  He  had  resided  in  Calcutta  for  about  three  years,  and  had 
lived  freely,  but  had  never  sufiered  from  dysentery.  He  had  been 
taken  ill  about  end  of  March  with  fever  and  rapidly  increasing  pro- 


LECT.  V.  TROPICAL    ABSCESS.  201 

stration.  He  had  no  pain  in  side,  no  diarrhoea,  and  no  jaundice,  but 
about  April  12  a  tumour  made  its  appearance  below  right  ribs,  which 
rapidly  increased  until  19th,  when  it  was  opened  with  a  large  trocar 
and  upwards  of  a  pint  of  matter  let  out.  The  cannula  was  left  in  the 
wound,  and  on  21st  the  patient  was  put  on  board  the  overland  steamer 
in  so  prostrate  a  state  that  he  was  hardly  expected  to  recover.  He 
slowly  improved,  however,  during  voyage,  and  cannula  was  removed 
at  Aden  about  a  fortnight  afterwards.  I  found  an  opening  with  pout- 
ing granulations  about  half-way  between  umbilicus  and  ribs,  and  2  in. 
to  right  of  mesial  line,  from  which  about  two  drachms  of  thin  pus 
escaped  daily.  The  patient  was  weak  and  anaemic,  but  in  other 
respects  appeared  to  have  nothing  amiss.  He  was  treated  with  mineral 
acids,  quinine,  and  iron,  and  within  three  months  he  had  regained  his 
usual  health  and  strength.  There  was  then  no  evidence  of  enlarge- 
ment of  liver,  and  the  opening  had  permanently  closed.  (With  the 
exception  of  an  attack  of  gout  in  January,  which  he  had  previously 
suffered  from,  and  of  which  disease  his  father  had  died,  he  remained  in 
good  health  until  he  returned  to  India  in  February  1868.) 

Case  LXXKII.  is  an  example  of  tropical  abscess  of  the  liver 
without  local  signs,  and  it  shows  also  that  the  liver  may  be 
freely  probed  for  pus  with  a  fine  instrument  without  any  harm 
resulting. 

Case  JjXXXIl.-^Beep-seated  Abscess  of  Liver — Exploratory  Punctures 
without  result — Pleuro-pneumoyiia — Death. 

Mr.  0.  B ,  aged  42,  consulted  me  on  March  22, 1873.     He  had 

just  returned  from  India,  where  he  had  resided  for  nine  years,  and 
where  he  had  enjoyed  fair  health  until  3rd  of  last  January,  when  he 
had  been  seized  with  dengue  fever,  followed  by  an  attack  of  acute 
dysentery  which  had  quite  ceased  by  Jan.  25.  Ever  since,  however, 
he  had  suffered  from  weakness,  uneasiness  in  right  hypochondrium, 
slight  perspirations  during  sleep,  cold  creeping  sensations  down  back, 
and  audible  pulsation  in  right  ear  on  lying  down,  which  kept  him 
awake  at  night.  He  had  also  a  feeling  of  heaviness  at  epigastrium 
after  meals  ;  bowels  rather  costive  ;  urine  dark,  and  loaded  with  lithates ; 
pulse  108.  flight  lobe  of  liver  slightly  enlarged,  measuring  5  in,  in 
r.  m.  1.  Ordered  a  scruple  of  chloride  of  ammonium  three  times  a 
day ;  occasional  aperient  of  blue  pill  and  rhubarb  ;  to  rub  red  iodide 
of  mercury  over  liver  ;  and  to  avoid  stimulants.  On  March  31  he 
returned  a  good  deal  better  and  complaining  chiefly  of  atonic  dyspepsia, 
for  which  he  was  ordered  nitro-muriatic  acid  with  quinine  and  pep- 
sine.  After  this  he  got  very  much  better  and  married.  On  May  8 
he  returned,  and  stated  that  five  days  before  (during  cold  east  winds) 
he  had  been  seized  with  '  ague  ; '  severe  rigors  every  afternoon  followed 


202  ENLARGEMENTS    OF    THE    LIVER.  lkct.  t. 

by  great  heat  and  profuse  sweating,  and  that  ever  since  lie  liad  lost 
appetite.  Urine  was  again  loaded  with  lithates  and  contained  a  trace 
of  albumen ;  bowels  confined.  Ordered  an  aperient  of  calomel  and 
rhubarb,  an  effervescing  alkaline  draught,  and  gr.  xv  of  quinine  during 
sweating  stage.  These  large  doses  of  quinine,  followed  first  by  gr.  v, 
and  subsequently  by  gr.  x,  three  times  a  day,  failed  to  arrest  the  parox- 
ysms of  fever,  which  recurred  once  or  oftener  every  day,  and  at  irregu- 
lar hours.  Careful  observation  showed  that  he  was  never  entirely  free 
from  pyrexia,  pulse  varying  from  84  to  108,  and  temperature  from  100° 
to  102°.  Urine  was  still  loaded  with  lithates  and  contained  a  trace  of 
albumen  ;  there  was  profuse  sweating  during  sleep,  and  patient  became 
daily  thinner  and  weaker.  Although  there  was  no  local  bulging, 
oBdema,  or  tenderness  over  liver,  an  abscess  in  that  organ  appeared  to 
ofier  the  only  solution  of  the  symptoms,  and  it  was  determined  to  ex- 
plore for  it.  Accordingly,  on  May  27  a  small  trocar  was  introduced 
by  Mr.  De  Morgan  to  depth  of  three  inches  into  right  side  of  epigastrium 
where  liver  appeared  to  be  slightly  enlarged,  and  on  June  12  two 
other  punctures  to  depth  of  4  or  5  in.  were  made,  one  in  front  a  little 
above  first,  and  the  other  at  back  between  eighth  and  ninth  ribs,  and 
the  aspirator  was  applied.  On  both  occasions  only  a  few  drops  of  blood 
escaped.  The  punctures  were  not  followed  by  any  pain  or  aggravation 
of  general  symptoms,  but  patient  became  daily  weaker.  On  June  20 
signs  of  pleuropneumonia  of  lower  lobe  of  right  lung  set  in  ;  after  this 
rigors  and  perspirations  ceased,  hepatic  dulness  in  r.  m.  1.  receded  one 
inch  from  nipple,  and  prostration  rapidly  increased  until  death,  which 
was  preceded  by  slight  hemoptysis  on  June  28. 

AutoiJsy,  by  Dr.  H.  W.  Hubbard,  who  had  attended  patient  since 
May  12. — An  abscess  containing  about  10  ounces  of  thick  yellow  pus 
in  upper  and  back  part  of  right  lobe  of  liver,  within  half  an  inch  of 
surface.  Rest  of  liver  congested,  but  otherwise  healthy.  Not  the 
slightest  sign  of  peritonitis  or  extravasation  in  situation  of  punctures, 
nor  in  fact  anything  to  show  where  they  had  been  made.  Upper  sur- 
face of  liver  corresponding  to  abscess,  and  also  base  of  right  lung,  ad- 
herent to  diaphragm  by  recent  lymph.  Extensive  pneumonia  of  lower 
lobe  of  right  lung.  The  abscess  was  still  confined  to  liver,  and  diminu- 
tion of  hepatic  dulness  in  front,  observed  during  life,  was  due  to  liver 
having  bulged  less  forward,  and  pointed  more  up  towards  lung. 

M}'  main  object  in  di-awing  your  attention  to  the  following 
case  is  that  an  absence  of  any  elevation  of  teniperatui'e  led,  in 
the  first  instance,  to  an  error  in  diagnosis.  Notwithstanding 
the  previous  history  of  dysentery  and  diarrhoea,  and  the  evidence 
of  gastric  and  hepatic  derangement  immediately  before  the 
acute  attack,  the  severity  and  the  paroxysmal  character  of  the 
pain,  associated  with  tenderness  and  obscure  swelling  in  the 


JLECT.  V.  TROPICAL   ABSCESS.  203 

region  of  tlie  gall-bladder,  but  unattended  by  any  sign  of  fever, 
pointed  to  a  calculus  in  the  cj'stic  duct  as  the  probable  cause 
of  the  attack.  The  progress  of  the  case,  however,  made  it 
probable  that  the  cause  of  the  pain  was  an  abscess,  which  ulti- 
mately discharged  itself  into  the  bowel.  The  precise  seat  of  the 
abscess  is  somewhat  doubtful.  The  fact  of  the  pain  being  at 
first  referred  to  the  lower  part  of  the  abdomen,  and  the  almost 
instantaneous  discharge  of  matter  per  rectum  after  the  sensation 
of  bursting,  suggested  that  it  might  be  in  the  neighbourhood  of 
the  rectum ;  whereas  the  previous  history  of  dysentery,  the 
symptoms  of  hepatic  derangement  immediately  before  the  acute 
attack,  and  the  circumstance  of  there  being  an  obscure  swelling 
with  tenderness  in  the  region  of  the  liver,  which  disappeared 
after  the  discharge  of  matter,  were  in  favour  of  a  hepatic 
abscess.  The  supposition  of  an  abscess  in  the  gall-bladder, 
secondary  to  obstruction  of  the  cystic  duct  by  a  gall-stone,  was 
rendered  improbable  by  the  fact  of  the  abscess  discharging  it- 
self, without  any  evidence  of  antecedent  obstruction  of  the 
common  duct  (jaundice),  although  it  is  possible  that  an  inflamed 
gall-bladder  distended  with  pus  might  have  discharged  itself 
into  the  colon.  But  whatever  was  the  seat  of  the  abscess,  the 
point  of  interest  was  the  same,  viz.  that  an  abdominal  abscess 
existed,  which  for  dsijH  caused  intense  pain,  but  none  of  the 
usual  constitutional  symptoms  of  pyrexia.  The  cessation  of  the 
symptoms  in  the  second  attack,  without  any  obvious  discharge 
of  matter,  was  probably  due  to  the  discharge  being  less  sudden, 
and  to  the  pus  being  obscured  by  feecal  matter. 


Case  LXXXIII. — Hepatic  (?)  Abscess,  without  Elevation  of  Temperature, 

On  Feb.  18,  1875,  I  was  called  to  see  Mr.  A ,  aged  40,  in  con- 
sultation with  Dr.  Collyer,  of  Enfield.     Mr.  A had  been  in  China 

for  a  good  many  years,  bnt  for  last  five  years  he  had  resided  in  London, 
or  in  neighbourhood.  About  1865  he  had  contracted  dysentery  in 
China,  and  ever  since  he  had  sufiered  from  chronic  dysenteric  diarrhoea, 
from  three  to  five  stools  daily,  often  containing  blood  and  mucus,  and 
sometimes  attended  by  tenesmus.  Still  his  appetite  had  kept  good,  and 
his  body  was  fairly  nourished.  Nine  weeks  before  I  saw  him  he  began 
to  complain  of  loss  of  appetite,  nausea,  and  occasional  vomiting,  and 
he  became  sallow,  his  bowels  acting  as  usual.  He  went  about,  how- 
ever, untd  five  days  before  my  visit,  when  he  was  seized  with  severe 
pain  in  abdomen,  which  gradually  increased  until  night  of  Feb.  17, 
when  he  was  rolling  about  in  agony  for  several   hours,   and  was  only 


204  ENLARGEMENTS    OP    THE    LIVER.  lect.  v. 

relieved  after  repeated  and  large  doses  of  opium.  The  pain  at  first 
had  been  referred  rather  to  lower  part  of  abdomen  ;  but  when  I  saw 
patient  it  was  restricted  to  region  of  gall-bladder,  where  a  distinct, 
but  not  well-defined,  prominence,  about  size  of  an  orange,  could  be 
felt.  With  the  pain  there  had  been  frequent  rigors  and  retching,  but 
repeated  observations  with  thermometer  failed  to  discover  any  eleva- 
tion of  temperature,  and  there  were  no  perspirations.  At  time  of  my 
visit, temp.  90' 5°  F. ;  pulse  70  ;  tongue  thickly  coated,  yellowish  ;  much 
flatulent  distension  of  abdomen. 

Patient  was  ordered  rest,  hot  poultices  to  abdomen,  and  an  efferves- 
cing soda  draught,  with  liq.  op.  sed.  ]]\  xv,  every  four  hours  while  pain 
continued  severe. 

■  Pain  was  but  little  relieved  by  treatment.  It  continued  intense 
until  evening  of  21st,  when,  while  sitting  in  an  easy-chair  before  fire, 
he  experienced  a  sensation  as  if  something  had  given  way  in  region  of 
gall-bladder,  and  immediately  a  large  quantity — about  a  pint — of  yellow 
matter  was  discharged  per  rectum.  This  was  examined  microscopically 
both  by  Dr.  Collyer  and  by  his  partner,  and  was  found  to  consist  of 
true  pus.  A  good  deal  of  matter  came  away  next  day,  and  a  smaller 
quantity  on  2ord,  but  from  moment  of  first  discharge  pain  ceased. 
On  Feb.  24  patient  passed  only  a  little  blood  and  mucus.  After  this 
stools  became  more  natural ;  appetite  returned  ;  swelling  and  tender- 
ness disappeared  ;  and  patient  went  on  well  until  March  8,  when  pain 
returned  in  severe  paroxysms  as  before,  and  again  no  elevation  of  tem- 
perature. On  March  13,  when  I  paid  a  second  visit  to  patient,  pulse 
68  ;  temp.  99"2°  ;  still  paroxysms  of  intense  pain  and  retching  ;  tender- 
ness and  obscure  swelling  in  region  of  gall-bladder.  Pain  persisted 
for  five  or  six  days  longer,  and  then  subsided — this  time  without  any 
obvious  discharge  of  matter.  On  April  1  patient  visited  me  in  town, 
and  then  complained  of  nothing  except  his  usual  diandioja,  which  by 
April  14  had  greatly  abated  under  the  use  of  creasote  and  opium. 

Whatever  was  the  seat  of  the  abscess  in  Case  LXXXIII., 
there  can  be  no  doubt  that  in  the  following  case  an  enormous 
abscess  existed  in  the  liver,  and  was  rapidly  increasing  in  size, 
without  any  elevation  of  temperature.  The  case  in  this  respect 
was  no  doubt  exceptional,  but  I  am  inclined  to  think  that  it  is 
far  from  unique.  At  the  very  time  at  which  this  patient  was 
under  notice  I  saw  another  in  whom  a  similar  observation  had 
been  made.  It  is  difficult  to  account  for  the  absence  of  pyrexia 
while  extensive  suppuration  is  going  on  in  these  cases,  except 
on  the  supposition  that  the  morbid  process  here  entails  the 
destruction  of  an  organ  which  contributes  in  part  to  the  main- 
tenance of  the  animal  heat;  and  yet,  so  far  as  we  know,  the 
temperature  is  elevated  in  most  large  abscesses  of  the  liver* 


I.ECT.  V.  TROPICAL    ABSCESS.  205 

But,  whatever  be  the  explanation,  the  possibility  of  a  large 
abscess  existing  in  the  liver  without  any  elevation  of  tempera- 
ture is  a  fact  of  great  clinical  importance.  The  case  was 
further  interesting  as  showing  the  origin  of  the  secondary- 
abscesses  in  inflammation  of  the  small  branches  of  the  portal 
vein. 

Case  LXXXIV. — Tropical  Abscess  of  Liver — History  extending  over 
3-|-  years — Absence  of  Pyrexia — Paracentesis — Death. 

Lieut.  M.,  aged  25,  consulted  me  on  Dec.  1,  1873.  In  Nov.  1868  he 
first  went  to  India.  During  1869-70  he  had  ague  repeatedly,  and  in 
1871-72  he  had  repeated  attacks  of  congestion  of  liver,  but  it  was  not 
until  Dec.  1872,  after  much  exposure  to  sun,  that  he  first  began  to  get 
seriously  out  of  health.  He  then  got  enlargement  with  pain  in  liver, 
loss  of  appetite,  retching,  and  obstinate  constipation,  jaundice,  and 
sleeplessness,  and  after  some  weeks  attacks  of  shivering  followed  by 
sweating.  After  three  months  the  more  acute  symptoms  subsided,  but 
he  remained  very  weak,  and  the  left  lobe  of  liver  was  still  large  and 
painful.  In  April  1873  he  left  India  on  sick  leave,  and  in  June  he 
arrived  in  England.  He  continued  to  improve  until  middle  of 
November,  when  he  was  seized  with  pain  in  right  lobe  of  liver,  increased 
by  lying  on  left  side,  loss  of  appetite,  and  great  prostration,  and  when 
I  saw  him.  liver  measured  6  in.  in  r.  m.  1.,  but  no  sign  of  fluctuation, 
retching,  or  diarrhoea.  Pulse  108 ;  great  pallor.  He  was  ordered 
saline  aperients  and  large  doses  of  chloride  of  ammonium,  and  occasional 
doses  of  blue  pill.  Under  this  treatment  he  speedily  improved,  and  I 
did  not  see  him  again  ;  but  he  had  an  attack  of  a  similar  nature  in  his 
liver  about  once  a  month.  In  one  of  these  attacks  he  kept  his  bed  for 
six  weeks,  had  profuse  sweating  every  night,  and  lost  nearly  2  stone  in 
weight.  After  attack  was  over  he  quickly  rallied,  and  could  go  through 
much  hard  work,  but  with  the  return  of  the  attack  he  M'as  at  once 
prostrated.  During  attacks  liver  alwaj^s  enlarged,  and  urine  became 
very  dark  and  turbid,  but  in  intervals  it  was  pale  and  clear.  He  had  no 
rigors  with  attacks.  In  Aug.  1875  he  returned  to  India,  but  attacks 
continued  to  recur  ;  in  intervals  he  had  sometimes  diarrhoea,  and  he  was 
agaiu  sent  home  on  sick  leave  in  March  1876.  On  April  27  I  saw  him 
for  the  second  time  in  one  of  the  attacks.  He  was  very  prostrate  ;  great 
pallor  ;  liver  large — 6  in.  in  r.  m.  1.  ;  decided  tenderness  over  right 
floating  ribs  at  back,  but  no  bulging  or  fluctuation.  Temp,  normal. 
No  jaundice.  Four  days  before  he  had  been  so  well  that  he  had  felt  none 
the  worse  for  walking  fifteen  miles  ;  and  two  days  afterwards  (April 29) 
Ije  appeared  again  perfectly  well,  and  liver  was  reduced  to  5  in.,  its  upper 
border  in  front  still  ascending  about  an  inch  too  high.  On  May  12  he 
had  another  attack  ;  much  pain  in  liver,  which  agaiu  became  enlarged  ; 
great  thhst ;  obstinate  constipation  ;  urine  loaded  with  brick- dust  sedi- 


206  ENLARGEMENTS    OF    THE    LIVER.  lect.  v. 

ment:  pulse  100  ;  sleeplessness,  but  no  elevation  of  temperature  ;  no 
niglit-swcats,  rigors,  or  retelling.  After  about  a  fortnight  a  fluctuating 
swelling  began  to  appear  in  right  loin,  which  rapidly  increased. 
Patient  became  wasted  and  worn  ;  slept  none,  owing  to  gi'eat  pain  ; 
tongue  dry  and  red ;  and  on  May  30  diarrhoea  set  in,  five  or  six  stools 
a  day  ;  but  all  this  time  temp,  never  rose  above  normal,  even  under 
tongue  ;  no  rigors,  and  scarcely  any  sweating. 

On  June  6  he  was  admitted  into  St.  Thomas's  Hospital.  Very 
prostrate.  P.  122.  T.  98-4°  to  99-2°.  Kesp.  30.  Hepatic  dulness  in 
front  extended  from  nipple  to  one  inch  below  ribs  =  7  in. ;  lower  margin 
very  tender.  In  right  loin  was  a  prominent  fluctuating  swelling  mea- 
suring 8  in.  by  9,  very  tender.  Girth  of  abdomen  over  this  swelling 
19^  in.  on  right  side,  lof  on  left.  Much  pain  and  restlessness.  T. 
coated  and  red  ;  bowels  loose.  Urine  turbid,  and  contained  albumen. 
On  June  7,  18  ounces  of  thick  reddish-brown  pus  were  drawn  off 
from  abscess  by  aspirator.     No  relief  followed. 

Jiine  8.— P.  124  ;  T.  98-4°  to  98-G°.  Tongue  dry,  red,  and  glazed  : 
five  or  six  loose  motions  ;  17  oz.  of  similar  pus  drawn  off  by  exhausting 
syringe. 

June  10.— No  improvement.  P.  124  to  150.  Temp.  98-2°  to  99-5°. 
An  incision  Avas  made  into  swelling,  and  a  pint  of  pus  let  out ;  cavity 
was  washed  out  with  a  solution  of  chloride  of  zinc  (xx  gr.  to  1  oz). 
and  a  drainage-tube  fastened  in,  and  wound  dressed  antiseptically. 

This  operation  gave  great  relief,  but  diarrhoea  persisted.  On  June  12 
he  be^an  to  have  frequent  retching ;  on  June  13  constant  hiccough  ; 
on  June  16  rapid  breathing ;  tongue  dry  and  glazed,  and  latterly 
aphthous,  total  loss  of  appetite  ;  albumen  and  lithates  in  urine,  and 
daily  increasing  prostration  until  death  on  June  19.  After  operation 
temp,  never  exceeded  99'6°  and  varied  between  this  and  97'6°.  The 
principal  remedies  employed  were  large  doses  of  quinine,  opium,  bis- 
muth, and  stimulants. 

Autopsy. — No  recent  peritonitis,  but  general  adhesions  on  lower  sur- 
face of  liver  and  over  upper  surface  of  right  lobe.  Lower  margin  of 
right  lobe  of  liver  did  not  extend  beyond  margin  of  ribs  in  front ;  but 
posteriorly,  projecting  from  its  under  surface,  was  a  large  abscess  cavity, 
extending  upwards  to  lovver  border  of  seventh  rib,  and  downwards  to 
crest  of  ilium,  lying  in  front  of  right  kidney,  and  bounded  in  front  by 
a  thin  layer  of  peritoneal  adhesions.  Immediately  adjoining  this, but  more 
in  substance  of  liver,  was  an  irregular  abscess  about  1^  in.  in  diameter, 
communicating  on  the  one  hand  by  a  fistulous  passage  with  the  large 
abscess  cavity,  and  on  other  by  a  narrow  sloughy  opening  (apparently 
recent)  with  neck  of  gall-bladder.  This  abscess  contained  several  small 
gall-stones,  and  in  gall-bladder  were  about  a  dozen  black  gall-stones,  size 
of  peas,  and  some  thin  pus.  Throughout  liver  were  several  smaller 
abscesses,  one  near  anterior  end  of  falciform  ligament,  which  had  almost 
burst  and  was  covered  by  a  layer  of  recent  lymph  ;  another,  size  of  an 


LKCT.  V.  TROPICAL   ABSCESS.  20/ 

apple,  near  upper  surface  of  left  lobe  ;  and  on  under  surface  of  left  lobe, 
near  anterior  margin,  a  rounded  depressed  cicatrix.  On  cutting  into 
liver  also  were  a  number  of  sliarply  defined  pale  yellowisb  patcbes,  from 
6  to  18  lines  in  diameter,  surrounded  in  some  instances,  but  not  in  all, 
by  a  narrow  congested  zone.  Lobules  in  pale  patches  were  defined, 
though  here  and  there  outline  confused  ;  appearance  seemed  due  to 
local  angemia,  but  some  of  patches  were  softened  in  centre.  On  micro- 
scopic examination.  Dr.  Greenfield  ascertained  that  all  the  vessels  in  the 
pale  arese  were  filled  with  coagula.  The  branches  of  the  portal  vein 
were  filled  with  adherent  coagula,  and  their  coats  thickened  and 
infiltrated  with  leucocytes,  which  were  also  accumulated  around  them. 
The  branches  of  the  hepatic  artery  exhibited  the  reaction  of  amyloid 
degeneration.  The  hepatic  cells  were  swollen  and  full  of  granular  or 
fatty  matter  ;  many  appeared  to  be  breaking  up.  The  hepatic  vessels 
were  tilled  with  coagulum,  but  coats  were  not  thickened.  Liver 
weighed  111  oz.  Numerous  minute  round  and  oval  cicatrices  of 
former  ulcers  throughout  colon  and  rectum,  and  also  in  lower  part 
of  ilium ;  walls  of  bowel  not  thickened.  Some  glands  in  fissure 
of  liver,  large  and  softened  in  centre  into  pus.  Kidneys  slightly 
enlarged,  soft,  and  flabby ;  cortices  swollen ;  amyloid  reaction  of 
Malpighian  tufts.  Spleen  11  oz.,  firm,  with  early  waxy  degeneration. 
Patches  of  recent  bronchial  pneumonia  in  lower  lobe  of  both  lungs  ; 
heart  healthy. 


2o8  ENLARGEMENTS    OF    THE    LIVER. 


LECTURE    VI. 
ENLARGEMENTS  OF  THE  LIVER. 

CANCER. 

Gentlemen, — The  next  form  of  enlargement  of  the  liver,  the 
clinical  characters  and  treatment  of  which  have  to  be  considered, 
is  that  which  is  due  to  cancerous  deposit. 

XI.    CANCER    OF    THE    LIVER. 

Cancer  of  the  liver  may  be  recognised  by  the  following 
clinical  characters. 

1 .  The  size  of  the  liver  is  increased,  and  not  uncommonly 
the  enlargement  is  very  great,  so  that  the  organ  fills  a  great 
part  of  the  abdominal  cavity.  A  cancerous  liver  has  been 
known  to  weigh  384  ounces,  or  about  seven  times  the  normal 
weight.'  The  enlargement  is  progressive,  and  in  the  softer 
forms  of  cancer  may  be  so  rapid  that  a  weekly  increase  may  be 
noted.  On  the  other  hand,  it  must  be  remembered  that  the 
liver  ma}"  contain  a  considerable  amount  of  cancer,  and  yet  the 
enlargement  may  not  be  appreciable  during  life.  The  liver  may 
have  been  originally  a  small  one,  and  the  addition  of  the 
cancer  may  not  cause  it  to  project  beyond  the  costal  arch,  or 
the   lower  margin   may  be  overlaj^ped  by  a  distended  bowel. 

You  will  remember  the  case  of  Mary  T ,  a  very  fat  woman, 

54  years  of  age,  who  died  recently  in  the  hospital,  of  apoplexy 
supervening  upon  white  softening  of  the  brain  (with  hemiplegia), 
and  whose  liver  was  unexpectedly  found  to  be  studded  with 
large  cancerous  nodules,  although  the  organ  did  not  project  be- 
yond the  costal  arch,  and  there  had  been  no  symptoms  during 
life  of  disease  of  the  liver.  A  similar  observation  was  made  in 
two  other  cases,  which  I  shall  detail  to  you  (Cases  XCV.  and 
XCVI.).     I  have  known  a  cancerous  liver  weigh  only  27  ounces. 

2.  The  enlargement  is  usually  irregular,  from  the  presence 

'  See  Budd,  Dis.  of  Liv.  3rd  ed.  p.  407,  hihI  Piith.  Trims,  xviii.  p.  145. 


CANCER. 


209 


of  nodular  excrescences  of  cancer  projecting  fi'om  the  surface 
or  from  tlie  margin  of  the  liver,  which  can  often  be  felt  on 
jjalpation,  and  are  sometimes  even  visible  through  the  abdo- 
minal parietes.  Occasionally  the  cancerous  deposit  forms  one 
In.rge  excrescence  or  tumour  at  a  particular  part  of  the  organ. 
Dr.  Bright  has  recorded  some  remarkable  eases  in  which  the 
tumour  was  confined  to  the  left  lobe,  and  projected  downwards 
into  the  abdomen,  or  upwards  into  the  left  side  of  the  chest ;  ' 
and  the  specimen  I  show  you  here,  obtained  from  tbe  body  of 
a  patient  wbo  died  under  my  care  in  tlie  Fever  Hospital,  is 
another  illustration  of  the  same  condition  (Case  XCIV.).  More 
commonly  a  number  of  nodular  outgrowths,  about  the  size  of 
cherries  or  small  oranges,  project  from  the  portion  of  liver  which 
is  opposed  to  the  abdominal  parietes  (see  fig.  18).     Oarc  must 


Fig.    IS.     Shows  area   of  Hepatic  Dullness,   in    Hannah    C — 
■with  nodidated  lower  margin. 


—   (Case   LXXXV.), 


be  taken  not  to  mistake  for  such  excrescences  the  rio-id  bellies 
of  the  recti  muscles  (see  page  15).  It  is  necessary  also  to  re- 
member that  a  nodular  character  is  not  essential,  as  might  be 
inferred  from  some  descriptions,  to  cancerous  enlargement  of 
the  liver.  In  certain  cases  the  cancer  is  not  deposited  in  the 
liver  in  isolated  nodules,  but  is  infiltrated  through  the  hepatic 
tissue  in  such  a  way  that,  although  the  organ  may  be  greatly 
enlarged,  its  natural  outline  is  but  little  altered ;  and  even  in 

'  ALclom.  Tumours,  Sjd.  Soc.  Ed.  pp.  261  and  308. 


2IO  ENLAKGEMEHTTS    OF    THE    LIVER.  lect.  ti. 

the  nodular  form  of  cancer,  the  portion  of  liver  below  the  ribs 
is  sometimes  quite  smooth  (Cases  LXXXVl.  and  LXXXVIIL). 

3.  The  enlargement  feels  very  hard  and  resisting-  on  palpa- 
tion, and  nowhere  exhibits  any  fluctuation.  In  rare  cases  some 
of  the  cancerous  nodules  may  be  so  softened  as  to  present  ob- 
scure fluctuation.  Now  and  then  the  excrescences  develope 
and  grow  while  the  patient  is  under  observation.  This  circum- 
stance, or  the  feeling  of  a  depression  in  the  centre  of  the  ex- 
crescences, will  plaije  their  cancerous  nature  beyond  a  doubt. 

4.  A  cancerous  liver  is  very  often  painful  and  tender  on 
pressure,  and  the  pain  radiates  to  the  shoulder,  back,  and  loins. 
At  first  there  may  only  be  a  feeling  of  weight  and  uneasiness 
in  the  right  hypochondriaim,  but  after  a  time  there  are 
paroxysms  of  lancinating  ^pain  awaking  the  j)atient  at  night, 
and  acute  tenderness ;  and  both  are  particularly  severe  in  cases 
where  the  growth  is  rapid,  or  where,  as  often  happens,  there  is 
inflammation  of  the  superimposed  peritoneum.  The  tenderness 
is  usuall}^  most  marked  over  the  prorninent  nodules.  But  many 
cases  of  cancerous  liver  are  met  with  in  which  there  is  little  or 
no  pain  from  first  to  last.  Not  long  ago  I  had  three  patients 
under  my  care  at  one  time  in  which  this  was  the  case. 

5.  Jaundice  is  present  in  a  large  number  of  cases,  and  when 
once  develojoed  it  rarely  disappears.  The  coexistence  of  en- 
largement of  the  liver  with  persistent  jaundice  ought  always  to 
raise  the  suspicion  of  cancer.  The  jaundice  is  in  rare  cases 
independent  of  obstruction  of  the  bile.-duct ;  far  oftener  it  results 
from  the  compression  or  Obliteration  of  the  bile-duct  by  a  can- 
cerous mass  in  the  liver  or  by  enlarged  glands  in  the  portal 
fissure.  If  the  ducts  be  ndtiJhus  compressed,  almost  the  whole 
of  the  secreting  tissue  may  be  destroyed  without  any  jaundice 
resulting.  Of  91  cases  of  cancer  of  the  liver  collected  by 
Frerichs,  52  died  without  ever  having  been  jaundiced. 

6.  Fluid  in  the  i^eritoneum  is  observed  in  more  than  one-half 
of  the  cases  of  cancer  of  the  liver  before  tlie  fatal  result.  Most 
commonly  it  concurs  with  jaundice,  or  each  symptom  may  exist 
indepcnd.M.tly  (see  Cases  LXXXV.,  LXXXVl.,  and  LXXXVII.). 
The  fluid  when  copious  is  usually  a  simple  dropsical  collection, 
due  to  compression  or  obstruction  with  cancerous  matter  of  the 
trunk  or  large  branches  of  the  portal  vein,  but  the  amount  is 
usually  small  as  contpared  with  what  is  observed  in  cirrhosis, 
although  now  and  th^n  it  collects  with  a  rapidity  rarely  seeii 
in  cirrhosis.  Considering  how  often  the  trunk  or  branches  of 
the  portal  vein  become  obstructed  with  cancerous  matter,  it  is 


LECT.  VI.  CANCEE.  211 

remarkable  that  the  branches  of  the  hepatic  vein  usually  escape. 
Very  often  small  collections  of  fluid  are  the  i-esult  of  a  chronic 
peritonitis  originating  on  the  surface  of  the  liver,  and  I  have 
known  a  collection  of  this  sort  become  encysted  above  the 
liver  so  as  to  embarrass  the  diagnosis.  Now  and  then,  as  in 
Cases  XCIIT.  and  XCI.V.,  blood  is  throvN^n  out  into  the  peri- 
toneum from  a  rupture  in  a  fun  gating  or  softened  cancerous 
mass  in  the  liver. 

7.  The  superficial  abdominal  veins  are  only  enlarged  in. 
those  comparatively  rare  cases  where  the  portal  circulation  is 
seriously  obstructed. 

8.  Enlargement  of  the  spleeii  is  rare,  and  this  constitutes 
an  important  distinction  of  the  cancerous  from  the  waxy  or 
cirrhotic  liver. 

9.  The  constitutional  symptoms,  in  the  first  place,  are 
mainly  those  of  deranged  digestion,  such  as  nausea,  flatulence, 
and  constipation,  and  occasionally  attacks  of  vomiting  or 
diarrhoea,  with  aching  pains  in  the  muscles  and  joints  and 
progressive  emaciation.  A  short  dry  cough  is  not  uncommon. 
When  the  cancer  grows  rapidly,  there  may  be  a  certain  amount 
of  pyrexia  (Case  XCI.) .  The  urine  is  invariably  scanty  and  high- 
coloured,  and  deposits  abundance  of  lithates  and  dark  pigment 
unless  the  patient  has  been  exhausted  by  vomiting  or  diarrhoea. 
Before  the  disease  has  lasted  long,  the  patient  presents  in  a 
marked  degree  the  phenomena  of  the  cancerous  cachexia — 
extreme  anaemia,  with  an  earthy  chlorotic  colour  of  the  integu- 
ments (unless  there  be  jaundice),  and  rapidly  increasing  debility 
and  emaciation.  These  symptoms  are  always  aggravated  by 
the  coexistence  of  cancer  of  the  stomach.  As  a  rule,  constitu- 
tional symptoms  precede  for  some  time  both  pain  and  jaundice, 
and  for  a  long  time  they  may  be  the  only  evidence  of  the 
disease,  there  being  no  enlargement  of  the  liver,  pain,  jaundice, 
or  ascites.  A  temporary  gain  in  weight  and  strength  under 
treatment  is,  however,  not  incompatible  with  cancer  of  the  liver. 

10.  Cancer  of  the  liver  is,  in  most  cases  (fully  three- fourths), 
secondary  to  cancer  of  some  other  organ,  such  as  the  stomach, 
uterus,  the  female  breast,  the  rectum,  or  the  vertebrae.^  In  more 
than  one-third  of  the  cases  it  is  secondary  to  cancer  of  the 
stomach.^     The  sjmiptoms  of  cancer  in  these  various  organs  will 

•  The  nodular  variety  is  most  commonly  secondary. 

^  According  to  Sir  W.  Jenner  (Erit.  Med.  Jnum   1869, 1.,  205)  cancer  passes  from 

p  '2 


212  ENLARGEMENTS    OF    THE    LIVER.  i.kct.  vi. 

therefore  materially  aid  the  dia<2;nosis.  Even  when  the  cancer 
is  deposited  first  in  the  liver,  other  parts,  such  as  the  coeliac, 
mediastinal,  inguinal,  and  cervical  glands,  and  the  lungs,  are 
apt  to  become  affected,  and  thus  throw  fresh  light  on  the 
primary  disease  (see  Case  LXXXVII.).  The  diagnosis  is  also 
in  many  cases  greatly  assisted  by  the  presence  of  a  small  mass 
of  cancerous  induration  in  the  abdominal  wall  around  the  navel. 

11.  Cancer  of  the  liver  alwnys  runs  a  rapid  course.  The 
medullary  cancer  often  grows  very  rapidly,'  and  is  fatal  within  a 
few  weeks  or  months  ;  and  although  scirrhus  is  said  sometimes  to 
last  for  two  years, ^  it  is  rarely  prolonged  beyond  twelve  months. 
The  very  fact  of  an  enlargement  of  the  liver  having  lasted 
much  longer  than  this  would  be  an  argument  against  its  being 
due  to  cancer. 

12.  The  diagnosis  is  often  assisted  by  the  circumstances 
under  Avhich  the  disease  occurs. 

a.  The  age  of  the  patient  is  sometimes  of  assistance  in 
diagnosis.  Cases  are  extremely  rare  where  the  liver  is  primarily 
affected  with  cancer  before  35  or  40.  Secondary  cancer  of  the 
liver,  it  is  true,  may  occur  at  any  age,  but  then  the  primary 
disease  will  point  to  the  nature  of  the  case. 

h.  In  a  large  proportion  of  cases  there  is  no  difficulty  in 
tracing  a  history  of  cancer  in  the  family.  In  the  course  of  my 
practice  I  have  known  two  sisters  die  of  cancer  of  the  liver,  in 
one  instance  within  a  fortnight,  and  in  another  within  a  few 
months  of  one  another. 

c.  In  a  large  proportion  of  cases  it  will  be  found,  whether 
a  family  taint  can  be  traced  or  not,  that  the  first  symptoms  uf 
indisposition  have  been  preceded  by  protracted  grief  or  anxiety. 

13.  The  diseases  most  likely  to  be  mistaken  for  cancer  of 
the  liver  are  waxy  disease,  interstitial  hepatitis  or  cirrhosis, 
syphilitic  disease,  catarrh  of  the  bile-ducts,  impacted  gall-stone, 
multilocular  hydatid,  and  pysemic  abscess  (p.  224.)  Case  XCII. 
also  shows  how  it  might  be  possible  to  mistake  cancer  of  the 
liver  for  even  simple  hydatid. 

a.  The  smooth  infiltrated  form  of  cancer  may  be  mistaken 
for  waxy  degeneration.  In  both  there  is  a  smooth,  uniform, 
very  hard  enlargement  of  the  liver;  but  in  the  waxy  enlarge- 

the  liver  to  the  stomach  oftcnor  th.-in  in  the  opposite  direction,  but  this  is  contrary  to 
my  experience. 

'  In  one  case  Dr.  Farre  calculated  that  in  ten  days  tlic  liver  acquired  an  addition 
equal  to  5  lbs.     Mori, id  Aratomy  of  tlio  Liver,  p.  28. 

2  Budd,  Dis.  of  Liver,  3rd  ed.  p.  413. 


lECT.  VI.  CANCEE.  213 

ment  the  progress  of  tlie  disease  is  slow,  there  is  an  absence  of 
pain  or  of  the  cancerous  cachexia,  and  there  is  usually  also 
enlargement  of  the  spleen,  with  albuminuria,  and  a  history  of 
constitutional  sj^philis,  caries  of  bone,  or  protracted  discharge 
from  a  suppurating  surface ;  whereas  in  cancer  there  is  no  en- 
largement of  the  spleen  or  albuminuria,  but  the  course  of  the 
disease  is  rapid,  and  there  are  pain,  cachexia,  and  often  signs 
of  cancer  elsewhere.  Rare  cases,  where  cirrhosis  and  waxy 
disease  coexist  (see  pp.  32  and  47),  may  be  mistaken  for  nodular 
cancer.  In  both  there  may  be  a  nodulated  hard  enlargement 
of  the  liver  with  ascites.  The  points  of  distinction  are  the  same 
as  between  the  smooth  form  of  waxy  disease  and  cancer. 

h.  In  cirrhosis  the  liver  may  be  large,  nodulated,  and  tender, 
and  there  may  also  be  jaundice  and  ascites  (see  p.  139).  It  will 
be  distinguished  from  cancer  by  the  previous  habits  of  the 
patient,  a  history  of  alcoholic  dyspepsia  with  morning  sickness, 
and  the  venous  stigmata  on  the  cheeks. 

c.  Syphilitic  enlargement  of  the  liver — either  interstitial 
hepatitis  with  projecting  gummata,  or  waxy  liver  indented  by 
deep  cicatrices — may  be  mistaken  for  cancer  (see  p.  147).  In 
both  affections  there  may  be  a  large  nodulated  tender  liver, 
with  jaundice,  ascites,  and  severe  pain ;  but  the  syphilitic 
disease  may  often  be  distinguished  by  the  comparatively  early 
age  of  the  patient,  the  previous  history,  and  the  existence  of 
other  evidences  of  syphilis. 

d.  Jaundice  from  catarrh  of  the  bile-ducts,  when  it  persists 
for  several  months,  and  is  associated,  as  it  may  be,  with  nausea, 
retching  and  emaciation,  may  be  mistaken  for  cancer  (see 
p.  153).  It  is  true  that  in  catarrh  of  the  bile-ducts  there  is  little  or 
no  pain  and  rarely  much  enlargement  of  the  liver.  Still, 
when  jaundice  supervenes  for  the  first  time  in  an  elderly 
person  who  is  not  the  subject  of  gout  or  of  constitutional 
syphilis  (see  p.  154),  and  is  persistent,  it  is  most  probably  due  to 
cancer  of  the  liver  or  in  its  vicinity,  notwithstanding  the  absence 
of  pain,  vomiting,  or  any  physical  signs  of  tumour,  and  in  any  case 
this  view  would  be  favoured  by  a  family  history  of  malignant 
disease. 

e.  A  gall-stone  impacted  in  the  common  bile-duct  may  be 
mistaken  for  cancer  of  the  liver.  In  both  affections  there  may 
be  intense  jaundice  with  paroxysms  of  severe  pain,  vomiting, 
emaciation,  and  loss  of  strength.  But  in  cancer  the  emacia- 
tion and  failure  of  health  precede  for  some  time  the  pain  and 


214        "  ENLARGEMENTS    OF    THE    LIVER.  lkct.  ti. 

jaundice,  wherefis  in  gall-stone  the  patient  has  been  in  his 
usual  health  until  his  sudden  seizure  with  biliary  colic,  and  very 
often  there  is  a  history  of  previous  attacks.  In  cancer  the 
vomiting  and  pain  may  occur  independently,  whereas  in  cancer 
thej'  are  more  commonly  simultaneous.  The  concurrence  of 
ascites  could  of  course  not  be  accounted .  for  by  gall-stones 
alone;  but  in  a  future  lecture  I  shall  have  occasion  to  point  out 
to  you  that  gall-stones  are  not  unfrequently  followed  b}"-  cancer 
of  the  gall-bladder  and  liver.     (See  also  Case  LXXXIX.) 

Occasionally  it  will  be  tolerably  clear  from  the  symptoms 
that  the  patient  is  the  subject  of  malignant  disease,  although 
the  seat  of  the  disease  may  be  doubtful,  whether  it  be  in  the 
liver  or  in  some  adjoining  part,  such  as  the  stomach  or  omen- 
tum :  but  this  is  a  difficulty  of  little  moment  as  regards  either 
prognosis  or  treatment. 

/.  A  multilocular  hydatid  tumour  of  the  liver  may  present 
all  the  clinical  characters  of  cancer,  viz.  a  hard  nodulated 
tumour,  intense  and  persistent  jaundice,  ascites,  oedema  of 
the  legs,  and  rapidly  increasing  emaciation  and  prostration. 
Vomiting  is  a  common  symptom  in  cancer,  but  has  rarely 
been  observed  in  multilocular  hydatid ;  whereas  in  the  latter 
affection  there  is  almost  invariably  considerable  enlargement 
of  the  spleen,  which  Frerichs  noted  in  only  12  out  of  91  cases 
of  cancer.  A  duration  much  in  excess  of  twelve  months 
would  be  opposed  to  cancer  ;  but  although  multilocular  hydatid 
has  been  known  to  last  for  years,  in  most  cases  its  course  is 
as  rapid  as  that  of  cancer.  It  follows  that  an  absolute  diagnosis 
between  the  two  affections  would  in  many  cases  be  impossible ; 
but  considering  its  rarity,  multilocular  hydatid  is  not  often 
likely  to  embarrass  the  diagnosis  (see  Lecture  VII.). 

Treatment. — The  treatment  of  cancer  of  the  liver  must  be 
entirely  palliative.  There  is  no  known  remedy  which  can  arrest 
or  retard  its  progress.  Mercur}',  iodine,  arsenic,  and  the 
Sanguinaria  Canadensis,  which  at  different  times  have  been 
recommended  for  the  purpose,  have  been  shown  to  be  worse 
than  useless.  In  none  of  the  many  diseases  of  the  liver  for 
which  it  has  been  the  fashion  to  give  mercury,  has  it  been  pro- 
ductive of  so  much  injur}'  as  in  cancer.  TJie  treatment  must 
be  restricted  to  supporting  the  patient's  strength  and  nutrition 
by  appropriate  food,  correcting  errors  in  digestion,  relieving 
pain,  and  procuring  sleej). 

1.  Tlie    diet   ouirht   to  be    nutritious,    but   moderate   and 


LKCT.  VI.  CANCER.  215 

digestible,  and  ought  to  contain  a  large  proportion  of  the  nitro- 
genous principles  of  food,  and  comparatively  little  of  saccharine 
and  oily  substances  which  are  calculated  to  increase  the  work 
thrown  upon  the  liver.  Alcoholic  stimulants  will  often  be 
necessary  in  the  advanced  stages  of  the  disease,  but  ought  to 
be  given  in  moderation  and  well  diluted.  It  must  not  be  for- 
gotten that  an  excess  of  nutriment  or  stimulants  may  feed  the 
disease  instead  of  nourishing  the  patient.  In  those  hopeless 
cases  where  the  primary  disease  is  cancer  of  the  stomach,  the 
diet  must  consist  mainly  of  milk  and  animal  soups  and  jellies. 

2.  Various  remedies  will  often  be  necessary  to  correct  errors 
in  digestion.     For  vomiting,  bismuth,  hydrocyanic  acid,  lime- 
water,  creasote,  nux  vomica,  or  ice,  will  be  useful,  and  likewise 
the  occasional  application  to  the  epigastrium  of  a  sinapism  or 
small  blister ;  in  the  latter  case,  advantage  is  sometimes  also 
derived  from  sprinkling  over  the  blistered  surface  a  qua^rter  of 
a  grain  of  morphia.     The  use  of  blisters  for  any  other  object 
can  do  little  good,  and  may  weaken  the  patient  besides  putting 
him  to  unnecessary  pain.     Flatulence  will  be  relieved  by  the 
ethers  and  essential  oils,  but  better  still  by  sach  remedies  as 
charcoal,  creasote,  or  carbolic  acid,  which  absorb  the  gas,  or, 
by  arresting  decomposition,  prevent  its  formation.     A  dose  of 
from  ten  to  thirty  minims  of  a  saturated  aqueous  solution  of 
carbolic  acid,  with  a  few  drops  of  chloric  ether  in  peppermint 
water,  is  sometimes  a  most  effectual  remedy  for  this  symptom. 
The  bowels  are   often  constipated,  and  will  require  relief,  but 
care  must  be  taken  to  avoid  castor- oil  and  powerful  purgatives, 
which  will  either  nauseate  the  stomach  or  lower  the  patient  b}""^ 
producing  copious  watery  discharges.    Four  or  five  grains  of  the 
compound  rhubarb  pill  with  a  grain  of  blue  pill  and  a  grain  of 
extract  of  henbane,  will  usually  produce  the  desired  result  satis- 
factorily and  safely,  or  the  bowels  may  be  cleared  out  from  time 
to  time  by  a  simple  enema.    The  compound  liquorice  powder  of 
the  Prussian  Pharmacopoeia  is  also  useful  for  the  same  purpose. 
3.  Sooner  or  later,  in  most  cases,  anodynes  will  be  necessary 
to  relieve  pain   or   procure    sleep.      The   hydrate   of  chloral, 
belladonna,  conium,  or  Indian  hemp,  will  often  be  found  useful 
for  these  objects,  and  ought  to  receive  a  trial  in  the  first  in- 
stance ;  but  in  most  cases  it  will  be  necessary  to  have  recourse 
ultimately  to  one  of  the  various  preparations  of  opium  or  mor- 
phia.    The  solution  of  the  bimeconate  of  morphia,  which  is  of 
the  same  strength  as  laudanum^  has  less  tendency  to  derange 


2l6  ENLAEGEMENTS    OF    THE    LIVEK.  lect.  ti. 

the  stomach  or  constipate  the  bowels  than  most  other  forms  in 
which  opium  is  given ;  and  these  disadvantages  of  opium  will 
also  be,  in  a  great  measure,  avoided  by  the  subcutaneous  injec- 
tion of  morphia.  In  many  cases  I  have  known  great  relief 
obtained  from  a  silvered  pill  containing  one  drop  of  creasote, 
quarter  of  a  grain  of  extract  of  nux  vomica,  and  from  a  sixth 
to  half  a  gi-ain  of  morphia,  twice  or  three  times  daily.  Lastl}', 
poultices  and  warm  fomentations,  with  or  witliovit  a  few  leeches, 
may  be  required  for  intercurrent  attacks  of  peri-hepatitis. 

The  following  cases,  which,  with  three  exceptions,  have  been 
under  your  observation,  illustrate  the  remarks  that  have  now 
been  made  on  cancer  of  the  liver. 

Case  LXXXV. — Cancer  of  Liver  and  Ovanj — Jaundice,  hut  no  Ascites. 

Hannah  C ,  aged  50,  a  cook  of  large  build  and  rather  stout, 

married,  a  mother  of  one  child,  adm.  into  Middlesex  Hosp.  on  July  28, 
1803.  She  stated  that  for  many  years  she  had  been  subject  to  '  bihous 
attacks'  (vomiting  and  headache),  but  that  about  two  years  before 
admission,  these  had  become  much  less  frequent  and  severe,  and  she 
had  enjoyed  good  health  until  about  ten  weeks  before  admission,  when 
slie  had  been  attacked  somewhat  suddenly  with  pain  in  epigastrium 
and  right  hypochondriura  and  in  both  shoulders,  accompanied  by  great 
languor,  and  followed  next  day  by  diarrhoea,  which  lasted  a  week.  A 
mouth  before  admission,  pain  had  become  much  increased,  and  urine 
was  noticed  to  be  of  a  dark  greenish-brown  colour ;  a  week  later  skin 
became  yellow,  and  since  then  patient  had  suff&red  much  from  itchi- 
ness.    From  first  she  had  been  losing  flesh. 

'I'lie  symptoms,  while  patient  was  under  observation,  were  as 
follows.  Skin,  conjunctivae,  and  serum  of  a  blister  of  a  bright  orange 
colour,  and  great  itchiness  of  entire  surface.  Tongue,  at  first  clean, 
became  afterwards  coated  with  a  thin  white  fur.  At  first  there  was 
no  vomiting,  but  frequent  attacks  of  nausea  and  a  feeling  of  distension 
and  oppression  after  meals.  Appetite  vciy  bad.  Motions  destitute  of 
any  trace  of  bile,  pnltaceou.s,  clay-coloured,  and  veiw  offensive.  Much 
pain  in  both  shoulders  and  in  epigastrium  and  right  hypochondrium  ; 
this  was  much  greater  a  few  days  after  admission  than  subsequently. 
Liver  jiiuch  enlarged,  hepatic  dnlness  in  right  mammary  line  extend- 
ing from  ^  an  inch  below  nipple  to  1^  in.  below  ribs,  and  measuring 
C)^  in.  ;  portion  of  liver  below  ribs  hard,  tender,  and  distinctly  nodu- 
lated (fig.  18,  p.  200).  No  ascites.  Urine  scanty,  only  about 
one-half  of  norn)al  quantity,  sp.  gr.  1030,  acid,  dark  like  porter,  and 
threw  down  a  copious  (lepohit  of  lithatcs;  it  contained  abundance  of 
bile-pigment,   but   no  bile-acids    (by  Harley's  test),  and  no  albumen. 


LKCT.  VI.  CANCEE.  217 

Pulse  GO  ;  cardiac  and  respiratory  signs  normal,  exce25t  that  occasionally 
'  crackling  sounds '  were  lieard  over  base  of  right  lung.  On  Aug.  G, 
and  again  on  Aug.  15,  it  was  noted  that  patient  vomited  after  her 
medicine.  On  Aug.  29  there  was  a  considerable  increase  of  paiii  and 
tonderness  in  abdomen,  with  vomiting  and  pinched  features.  Under 
treatment,  these  symptoms  abated  somewhat,  but  vomiting  returned 
from  time  to  time,  while  the  languor  and  prostration  i-apidly  increased. 
On  Sept.  28  vomiting  became  incessant,  and  from  this  date  patient 
gradually  sank  until  death  on  Oct.  3. 

Treatment  consisted  in  bismuth,  hydrocyanic  acid  and  opiates, 
sinapisms  to  epigasti'ium,  and  nutritious  but  digestible  food. 

Autopsy. — Body  well  nourished,  and  a  thick  laj^er  of  fat  everywhere 
beneath  skin,  in  omentum,  and  around  kidneys.  Tissues  throughout 
body  deeply  stained  with  bile.  I^o  fluid  in  peritoneum,  and  no  sign 
of  recent  peritonitis.  Mucous  membrane  of  stomach  and  intestines 
normal,  but  contents  of  bowel  contained  no  trace  of  bile,  and  none 
could  be  squeezed  from  gall-bladder  into  duodenum.  Liver  very  large, 
weighing  97  oz.,  and  its  right  lobe  measuring  13  in.  from  before 
backv/ards  ;  surface  studded  with  elevated  yellowish- white,  moderately 
firm  nodules,  varying  in  size  from  a  pea  to  a  walnut,  and  many  of  them 
depressed  in  centre.  Similar  masses  seen  in  interior  of  liver  on  sec- 
tion ;  one  mass,  size  of  a  large  orange,  occupied  entire  thickness  of 
right  lobe  in  front,  extending  back  to  transverse  fissure,  and  in  contact 
with  upper  surface  of  gall-bladder.  These  masses  yielded  a  creamy 
juice  on  section,  which  contained  characteristic  '  cancer-cells  ; '  some 
of  them  softened  in  centre  into  a  yellow  pulp,  and  here  cancer-cells 
contained  much  oil,  and  there  were  many  compound  granular  cells. 
Hepatic  lobules  between  cancerous  masses  had  a  peculiar  appearance  ; 
the  central  third  of  each  lobule  had  a  dark  olive-green  colour,  and 
hepatic  cells  in  it  contained  much  bile-pigment ;  the  outer  two  thirds 
were  pale-yellow,  and  there  the  secreting  cells  were  loaded  with  oil. 
Several  stellate  crystals  of  tyrosin  were  found  in  secreting  tissue. 
Gall-bladder  contained  no  bile,  but  was  filled  with  facetted  gall-stones. 
Hepatic  ducts  considerably  dilated,  but  common  duct  passed  into  a 
mass  of  dense  areolar  tissue  and  enlarged  glands  in  portal  fi.ssui'e, 
through  which  its  continuity  could  not  be  traced.  Capsule  of  Kver  at 
many  places  adherent  by  firm  fibrous  bands. 

Uterus  normal.  Left  ovary  as  large  as  .a  walnut,  rather  soft,  and 
nodulated;  it  contained  a  little  semi-flaid  dark  blood,  and  its  substance 
was  soft  and  yellow,  and  exuded  a  creamy  juice  containing  '  cancer- 
cells.'  A  cancerous  nodule,  size  of  a  pea,  projected  from  surface  of 
left  ovary.  Mesenteric  and  lumbar  glands  presented  no  abnormal 
appearance. 

Lungs  and  heart  normal,  with  exception  of  pulmonary  congestion 
and  patches  of  atheroma  in  mitral  flaps  and  in  commencement  of  aorta. 
No  cancerous  deposits  in  either  spleen  or  kidneys. 


2l8  EXLAECtEMENTS    of    the    liver.  lect.  vr. 

Case  LXXXVI. — Cancer  of  Uterus  andLiccr — Ascites^  hut  no  Jaundice. 

On  Oct.  18,  18G6,  Charlotte  D ,  aged  06,  was  transferred  to  my 

care  in  Middlesex;  Hosp.,  having  been  for  two  months  before  under  care 
of  Obstetric  Physician  for  cancer  of  uterus.  She  was  married,  and 
mother  of  nine  children  ;  catamenia  had  ceased  at  age  of  49.  Three 
years  before  she  came  under  my  care,  she  had  an  attack  of  what  ap- 
peared to  be  gall-stones,  sudden  spasmodic  pain  in  right  side,  with 
vomiting  and  slight  jaundice,  and  ever  since  she  had  suffered  from  a 
feeling  of  ixneasiness  and  fulness  below  right  ribs.  Twelve  months 
before,  she  first  noticed  a  slight  but  very  offensive  and  persistent  yellow 
discharge  from  vagina,  and  ever  since  she  had  suffered  from  costiveness 
and  pain  in  deffecation  and  some  difficulty  in  micturition.  On  two  oc- 
casions, nine  months  and  three  naonths  before  she  came  under  my  ob- 
servation, she  had  rather  copious  uterine  hsemorrhage,  lasting  for  about 
a  fortnight.  Two  months  before,  she  first  noticed  her  abdomen  to 
swell,  and  she  began  to  suffer  from  vomiting  after  food.  She  had  been 
losing  flesh  for  twelve,  and  rapidly  for  three  months. 

On  admission  patient  was  weak  and  emaciated,  and  her  countenance 
was  expressive  of  pain.  Extensive  induration  and  ulceration  of  cervix 
uteri  and  upper  part  of  vagina,  with  a  fetid  discharge.  Abdomen  much 
distended,  nieasai'ing  3of  in.  at  iimbilicus,  and  exhibiting  all  the  signs 
of  fluid  in  peritoneum.  Liver  much  enlarged,  in  r.  m.  1.  measuring  (j^ 
in.,  and  projecting  fully  2  in.  below  costal  margin ;  portion  that 
could  be  felt  hard  and  tender,  but  had  no  feeling  of  nodulation. 
Superficial  abdominal  veins  slightly  enlarged,  but  no  jaundice.  Tongue 
moist  and  slightly  furred ;  vomiting  had  ceased,  but  bowels  had  not 
acted  for  several  days.  Urine  loaded  with  lithates,  but  contained  no 
albumen.  No  anasarca  of  trunk  or  extremities.  Pul-se  108  and  feeble  ; 
no  dyspnoea;  cardiac  and  i-espiratory  signs  normal,  with  exception  of 
slight  dulneas  and  fine  crepitation  at  end  of  inspiration  at  base  of  right 

Patient  was  treated  with  bismuth  and  chloric  ether,  subcutaneous 
injections  of  morphia,  mild  laxatives,  and  a  nutritions  diet,  with  a  small 
allowance  of  brandy.  Vomiting  did  not  return  ;  but  every  night  she 
suffered  from  intense  pain  in  abdomen,  which  was  only  partially  relieved 
by  morphia  injections.  Belly  slowly  increased  in  size ;  prostration 
became  daily  greater,  until  death  occurred  on  Oct.  30. 

Autopsy. — Peritoneam  contained  several  quarts  of  turbid  scrum, 
with  flakes  of  soft  lymph,  chiefly  on  fundus  uteri  and  in  pouches  be  foi-e 
and  behind.  Cervix  uteri  entirely  destroyed  by  cancerous  ulceration, 
which  extended  for  1^  ia.  down  anterior  wall  of  the  vagina;  lower 
two-thirds  of  uterus  infiltrated  Avitli  cancerous  matter.  Lumbar  glands 
slightly  enlarged  from  cfincerous  deposit,  and  in  the  portal  fissure  was 
a  mass  of  enlarged  cancerous  glands  pressing  on  portal  vein.  Liver 
of  enormous  size,  weighing  11^   oz.,  and  jiortiou  ojjjiosed  to  thoracic 


j.KCT.  Ti.  CANCER.  .  219 

and  abdominal  wall  meastiring  7  in.  ;  it  was  studded  tlironghout  with 
numerous  isolated  nodules  of  cancer,  from  a  pea  up  to  a  walnut  in  size, 
but  none  of  them  mucli  raised  above  outer  surface,  so  that  portion  of 
organ  projecting  beyond  ribs  was  perfectly  smooth  and  even.  On 
section,  many  of  nodules  were  found  to  be  softening  in  centre  into  a 
flaky  serous  fluid.  On  microscopic  examination,  nodules,  both  at  cir- 
cumference and  in  centre,  were  seen  to  consist  mainly  of  nuclear  ele- 
ments, with  but  few  cells ;  hepatic  tissue  intervening  between  nodules 
free  from  cancerous  infiltration.  Mucous  membrane  of  stomach  and 
intestines  healthy,  but  small  nodules  of  cancer,  up  to  size  of  a  chei"ry, 
were  scattered  through  lower  lobe  of  right  lung. 

Although  no  opportunity  was  afforded  for  a  post-mortem 
examination  m  the  following  case,  the  diagnosis,  as  I  frequently 
pointed  out  in  the  wards,  was  sufficiently  clear. 

Case  LXXXVII. — Cancer  of  Liver,  Lunrfs,  and  Cervical  Glands — 
Jaundice  and  Ascites. 

John  B ,  aged  47,  a  coAvman,  adm,  into  Middlesex  Hosp.  Aug. 

2ri^,  1866.  Twelve  years  before  admission  he  had  been  confined  to  bed 
for  a  week  with  rheumatism ;  and  two  years  before  he  had  sufi'ered  for 
two  months  from  severe  pain  at  epigastrium,  usually  worse  after  food. 
With  these  exceptions,  he  had  enjoyed  good  health  until  eight  weeks 
before  he  came  to  hospital,  when  he  was  seized  somewhat  suddenly, 
while  at  work,  with  violent  pain  in  region  of  liver  and  stomach,  which 
never  ceased,  although  it  had  been  sometimes  more  severe  than  at 
others.  Eight  days  after  this  he  noticed  that  his  motions  had  lost 
their  colour,  and  that  urine  was  very  dark,  and  after  six  more  days, 
conjunctivae,  and  then  skin,  became  yellow. 

On  admission  patient  was  weak  and  emaciated,  and  had  intense 
jaundice  of  entire  surface.  He  complained  of  severe  pain  in  region  of 
liver,  coming  on  in  paroxysms,  which  would  last  for  many  hours,  were 
sometimes  attended  by  vomiting,  and  often  prevented  sleep.  Liver 
enlarged,  measuring  5^  in.  in  right  mammary  line  ;  in  epigastrium 
it  felt  hard  and  obscurely  nodulated,  and  was  very  tender.  No  tumour 
felt  corresponding  to  gall-bladder.  There  was  neither  ascites  nor  en- 
largement of  abdominal  veins  or  spleen.  Tongue  coated  with  a  creamy 
far  ;  bowels  costive  ;  motions  clay-coloured  and  very  offensive  ;  urine  of 
colour  of  porter,  and  contained  abundance  of  bile-pigment  but  no  al- 
bumen.    Pulse  96  ;  cardiac  and  respiratory  signs  normal ;  no  dropsy. 

Patient  was  treated  with  mineral  acids  and  gentian,  anodyne 
draughts  wibh  drachm  doses  of  tincture  of  henbane,  and  mild  laxatives. 

On  Aug.  28  he  first  noticed  a  tumour  on  left  side  of  neck,  imme- 
diately above  clavicle,  about  size  of  a  hen's  Bggi  hard,  nodulated, 
and  slightly  tender.  This  tumour  increased  in  size,  and  soon  became 
seat  of  severe  pain,  like  that  in  liver.     Patient  also  complained  often  of 


220  EXLAllGEMEXTS    OF    THE    LIVEE.  lkct.  yi. 

severe  pain  down  back,  but  no  tenderness  of  spine.  Indian  hemp  and 
henbane  failed  to  give  relief  to  these  pains,  and  on  Sept.  9  subcu- 
taneous injections  of  morphia  "were  resorted  to,  at  first  with  great 
benefit.  On  Sept  5  ascites  was  first  noticed,  which  from  this  date 
continued  to  increase,  and  on  Sept.  24  both  feet  and  lower  half  of  both 
legs  were  noted  as  SAVollen  and  oedematous.  Tumour  in  neck  now 
filled  up  whole  of  lower  triangle,  and  at  its  circumference  were 
several  large  and  movable  glands  quite  distinct  from  general  mass : 
patient  vomited  occasionally  after  breakfast,  and  became  daily  thinner 
and  weaker.  On  Oct.  1  he  was  noted  as  vomiting  almost  everything 
he  swallowed.  Pulse  84,  weak,  and  intermittent.  Ascites  and  tumour 
of  neck  continued  to  increase ;  liver  ajjpeared  larger  and  more  dis- 
tinctly nodulated  ;  and  pains  Avere  only  relieved  by  morphia  injections, 
Avhich  were  repeated  twice  daily.  No  cough,  and  respiration  slow  and 
easy,  but  over  middle  of  left  lung  posteriorly  marked  dulness  over  a 
space  3  or  4  in.  square,  with  absence  of  vesicular  murmur,  but  no 
friction  or  crepitation.  On  Oct.  5  left  arm  and  hand  oedematous,  and 
vomited  matter,  which  from  first  had  resembled  yeast,  was  found  to  con- 
tain abundance  of  sarcinas.  A  mixture  was  ordered  every  six  hours,  con- 
taining ten  minims  of  chloi'ic  ether  and  one  drachm  of  a  satui*ated 
aqueuus  solution  of  carbolic  acid  in  peppei-mint  water. 

Patient  was  now  so  weak  that  he  obviously  could  not  live  many 
days,  but  his  wife  came,  and  insisted  on  removing  him  to  country. 

Case  LXXXVIII. — Primarij  Liji  It  rated  Cancer  of  Liver — Great  Enlanje- 
ment,  hut  surface  suiuoth — No  Jaaiidlce  or  Ascites. 

On  Jan.   5,   1876,  Ann   G ,   aged  42,   was  sent  to  Samaritan 

Hosp.,  supposed  to  be  suffering  from  ovarian  disease.  On  Jan.  7  she 
Avas  transferred  to  St.  Thomas's-  No  history  of  malignant  disease  in 
family.  ^Mother  of  eight  children  and  had  three  miscarriages.  Cata- 
menia  had  ceased  five  years  before,  after  birth  of  last  child.  Left  eye- 
ball had  been  remoA'ed  3iyears  before,  owing  to  eti'ects  of  a  blow.  Six 
months  before,  Avhen  ap^jarently  in  perfect  health,  first  noticed  swell- 
ing below  riglit  ribs  which  gradually  tilled  abdomen,  and  at  same  time 
she  lost  flesh  and  strength.  For  two  months  had  suffered  much  pain 
in  abdomen,  and  for  five  days  had  noticed  swelling  of  legs  and  thighs. 

On  admission  :  Very  emaciated.  Abdomen  greatly  enlai-ged,  bulg- 
ing aljruptly  forwards  beloAV  ribs  ;  enlargement  greater  in  up})er  tlian 
in  lower  part ;  integuments  stretched  and  shining.  Girth  at  navel 
^■i\  in.,  and  half-way  between  this  and  sternum  33  in.  ;  from  ensiforui 
cartilage  to  navel  H^  in.  ;  from  navel  to  pubes  (j\  in.  No  sign  of  fluid 
in  j)eritoneum,  and  swelling  evidently  caused  by  a  very  large  liver, 
lower  margin  of  AvJiicii  can  be  felt  on  both  sides,  2^  in.  below  level  of 
umbilicus  ;  margin  of  right  lobe  more  rounded  than  that  of  left,  and 
the  two  separated  by  a  deep  indentation  rising  to  above  navel.  Upper 
margin  of  liver  does  not  rise  too  high  in  chest ;  total  hepatic  dulness 


i.ECT.  VI.  DAXCEE.  221 

in  r.  m.  1.  11  in.,  and  same  m  mesial  line.  Surface  of  swelling  slightly 
undulating,  but  free  from  excrescences,  and  not  tender  Consistence 
tense,  but  rather  elastic.  Suffers  much  from  constant  tightness  in 
tumour,  worse  after  meals  and  preventing  sleep,  and  has  occasionallj 
attacks  of  severe  'scraping'  or  cutting  pain.  Tongue  coated;  no 
appetite  ;  no  vomiting  ;  bowels  costive ;  no  jaundice.  Urine  1026, 
loaded  with  lithates  ;  no  albumen.  Pulse  96,  A  few  dry  bronchial 
rales  over  lungs. 

Became  rapidly  weaker  ;  vomiting  came  on  ;  and  died  on  Jan.  13. 

Autopsy. — Liver  greatly  enlarged,  corresponding  to  tumonr  observed 
during  life  ;  weighed  198  oz. ;  shape  normal ;  non-adherent ;  surface 
smooth  ;  left  lobe  as  large  as  an  ordinary  right ;  great  exaggeration  of 
central  fissure.  Enlargement  of  liver  due  to  extensive  cancerous  in- 
filtration of  left  lobe  and  to  a  considerable  extent  of  right ;  on  section 
a  few  isolated  nodules,  from  size  of  a  pin's  head  to  an  inch  in  diameter; 
but  none  projected  from  surface.  No  cancer  in  any  other  part  of  body. 
Spleen  7oz.,  dark  and  soft;  lungs  congested.  On  section  of  infiltrated 
new  growth  in  liver  it  was  pale  like  a  fatty  liver,  outlines  of  acini 
being  distinct.  Microscopic  examination  showed  that  it  had  ordinary 
structure  of  encephaloid  cancer. 

The  two  follov^ing  cases  are  remarkable  for  the  mode 
of  commencement.  In  Case  LXXXIX.  the  disease  seemed 
to  commence  in  the  gall-bladder  and  bile- ducts,  and  the 
history  in  the  first  instance  pointed  to  biliary  colic  and  gall- 
stones rather  than  to  cancer;  while  in  Case  XC,  where  the 
disease  perhaps  originated  in  the  right  kidney,  one  of  the  first 
symptoms  of  illness  was  ascites. 

Case  LXXXIX. — Cancer  of  Gall-hladder,  Bile-ducts,  Liver,  ^'c,  com- 
"inencing  ivith  severe  ]jain  liJce  that  of  Biliary  Colic— Jaundice — No 
Ascites. 

Anne  G ,  63,  adm.  into  St.  Thomas's  Hosp.  Xov.  19,  1875.     Xo 

history  of  malignant  disease  in  family.  Had  seven  children,  all  of 
whom,  as  well  as  husband,  had  died  of  consumption.  Had  been  of 
temperate  habits.  Had  suffered  now  and  then  for  a  year  or  two  from 
flatulence,  but  with  this  exception  she  had  been  in  her  usual  good 
health  until  three  weeks  before  admission,  when  one  day,  while  out 
washing,  she  had  been  suddenly  seized  with  a  sharp  shooting  pain  be- 
low right  ribs  in  front.  Pain  was  so  severe  that  she  could  scarcely 
walk  home.  It  kept  coming  on  in  paroxysms,  and  was  attended  by 
shivering  but  not  by  vomiting  ;  after  four  days  it  ceased,  but  a  day  or 
two  after  this  she  was  noticed  to  be  deeply  jaundiced,  and  she  had 
much  nausea.  On  cross-examination  patient  admitted  that  for  two  or 
three  months  before  attack  of  pain  strength  had  failed  a  little,  but  she 
had  followed  her  work  as  usual,  and  had  not  noticed  any  loss  of  flesh. 


222  ENLARGEMENTS    OF    THE    LIVEE.  lect.  vi. 

On  admission,  deeply  jaundiced ;  skin  vei'y  itchy  ;  urine  loaded 
witli  bile-pigment,  but  none  in  stools ;  hepatic  dulness  not  increased  ; 
slight  bulging  and  some  tenderness  corresponding  to  gall-bladder  ;  no 
ascites  ;  no  appreciable  abdominal  tumour.  Tongue  clean  ;  fair  appe- 
tite ;  pulse  70. 

Four  days  after  admission  had  an  attack  of  severe  pain  in  liver, 
lasting  about  half  an  hour.  These  attacks  recurred  first  at  intervals 
of  a  few  days  and  then  more  frequently  ;  they  were  not  attended  by 
vomiting.  Day  by  day  patient  grew  weaker  and  thinner,  and  there 
was  loss  of  appetite  and  much  nausea.  The  liver  gradually  increased 
in  size,  until,  on  Jan.  22,  it  measured  7  in.  in  r.  m.  1.  No  inequalities 
could  be  felt  on  its  surface  ;  no  tumour  appreciable  anywhere,  but 
always  much  tenderness  over  gall-bladder ;  no  ascites.  Death  by 
exhaustion  on  Jan.  26. 

Autopsy. — No  fluid  in  peritoneum.  Colon  and  duodenum  di'awn  up 
and  adherent  to  an  irregular  cancerous  mass  projecting  from  liver, 
occupying  situation  of  gall-bladder,  infiltrating  adjacent  part  of  liver 
and  extending  downwards  so  as  to  involve  head  of  pancreas.  Im- 
mediately above  pancreas  another  cancerous  mass  due  to  infiltration  of 
glands  in  that  region.  Duodenum  where  adherent  to  mass  narrowed, 
but  mucous  membrane  both  of  it  and  colon  healthy.  Gall-bladder 
shrunken  ;  walls  ^  in.  thick,  infiltrated  with  cancer  ;  inner  surface 
rough,  shaggy,  and  very  vascular  ;  cystic  duct  obliterated  ;  a  small 
rounded  oi'ifice  surrounded  by  granulations  at  fundus  where  it  had  been 
adherent  to  abdominal  wall.  Walls  of  common  and  of  hepatic  duct 
from  ^  to  I"  in.  thick  from  infiltration  with  new  growth,  this  infil- 
tration extending  both  downwards  towards  bowels,  and  upwards  for 
4  in.  into  substance  of  liver,  where  it  became  obliterated  and  em- 
bedded in  hard  new  growth.  No  gall-stones.  On  cutting  into  liver, 
bile-ducts  greatly  dilated  behind  seat  of  stricture,  forming  cystiform 
sacculations  filled  with  glairy,  colourless  fluid,  free  from  all  colour  of 
bile.  Scattered  through  substance  of  liver  were  numerous  nodules  of 
new  growth ;  and  in  centre  of  many  of  them  a  small  orifice  from  which 
a  drop  of  glairy  fluid  exuded  on  squeezing,  as  if  they  were  formed  by 
infiltration  of  walls  of  bile-ducts.  Portal  vein  not  obstructed.  Weight 
of  liver  7o  oz.  Spleen  6|  oz.  Commencing  granular  degeneration  of 
kidneys  ;  in  upper  lobe  of  right  lung  a  circumscrilied  ncAV  growth,  size 
of  a  walnut;  lower  lobe  studded  with  new  growths  from  size  of  a 
pin's  head  to  that  of  a  pea. 

Case  XC. — Cancer  of  rigid  Kidney,  Liver,  Si'leen,  ami  Tjungs. 
Ascites  tlie  first  symptom,  of  illness. 

John  !M ,  aged  37,  adm.  into  St.  Thomas's  Hosp.  March  9,  1875. 

No  evidence  of  malignant  disease  in  family.  Habits  temperate;  no 
history  of  syphi'i.s,  and  general  health  good.  For  three  f.r  four  months 
Ixjfore  Oiristmas  1874  had  felt  occasionally  a  fulness  and  tightness  of 


LECT.  Ti.  CAISTCER.  223< 

abdomen,  bnt  had  not  paid  much  attcBtion  to  it.  On  Dec.  28  liad  a 
more  severe  attack  than  usual  of  this  tightness,  and  after  this  it  be- 
came more  constant  and  was  increased  af  er  food.  Still  appetite  con- 
tinued good  ;  no  nausea  or  vomiting  ;  no  appreciable  emaciaiion  ;  and 
followed  employment  as  a  platelayer  until  Feb.  28,  when  he  was  sud- 
denly seized  with  great  tightness  and  pain  in  abdomen  ;  could  take  no 
food  ;  and  was  compelled  to  give  up  work  and  t-ake  to  bed.  From 
this  date  abdomen  continued  to  enlarge,  and  ho  was  slightly  yellow. 

On  admission,  sallow  and  anaemic,  and  conjunctivae  slightly  yellow. 
Still  complains  much  of  tightness  in  abdomen  and  of  dyspnoea  on  exer- 
tion. Girth  at  umbilicus  36  in.;  moder-c^te  ascites;  slight  oedema  of 
legs.  Liver  much,  enlarged,  dulness  commencing  ^  in.  below  rio-ht 
nipple,  and  from  this  to  lower  margin,  3  in.  below  ribs  in  r.  m.  1.  7  in.  • 
enlargement  uniform  ;  surface  smooth,  hard,  and  painless ;  left  lobe 
also  muck  enlarged.  Splenic  dulness  increased ;  and  lower  end  of 
spleen  felt  projecting  1^  in.  below  x'ibs.  Abdominal  veins  slightly  en- 
larged. Tongue  clean  :  appetite  faic- ;  no  vomiting  ;  bowels  confined. 
Complains  much  of  painful  tightness  of  abdomen  after  food.  Pulse  78  • 
heart  signs  normal.  Lungs  normal.  Urine  1017  ;  no  albumen,  but 
some  bile-pigment.     Temp.  99°. 

•The  treatment  at  first  consisted  in  the  perchloride  of  mercury  and 
bark,  with  aperients  ;  while  mercurial  and  belladonna  ointment  was 
applied  to  abdomen,  and  morphia  w^as  given  occasionally  to  relieve 
pain  and  procure  sleep.  On  March  12  two  srrall  excrescences  were 
discovered  on  surface  of  liver,  one  just  below  ensiform  cartilao-e  and 
the  other  on  left  lobe.  On  March  31  a  mixture  of  nux  vomica  and  acid 
was  substituted  for  the  mercurial.  On  April  12  patient  had  o-ained 
9  lbs.  in  weight  in  ten  days  and  12  lbs.  since  admission,  but  this  increase 
was  probabl}^  due  to  greater  accumulation  of  fluid  in  abdomen,  which 
now  measured  40  in. ;  parietes  attenuated  and  glazed  ;  more  oedema  of 
legs  ;  jaundice  scarcely  appreciable.  April  19 :  Seven  pints  of  fluid 
drawn  cfi"  by  aspirator,  reducing  girth  to  35  in.  and  givino-  great 
relief.  Fluid  rapidly  accumulated  again ;  much  pain  in  abdomen  • 
occasional  epistaxis.  On  April  28  girth  of  abdomen  ao-ain  40  in.  ■ 
patient's  weight  16  lbs.  more  than  on  admission.  On  May  7,  16  pints 
of  serum  removed  by  paracentesis,  and  after  this  liver  could  be  seen 

forming  a  large  prominent  tumour  between  sternum  and  umbilicus 

hard  and  nodulated.  Pain  again  relieved  by  operation,  but  exhaustion 
increased,  and  deatli  on  May  13. 

Autopsy. — Eight  pints  of  serum  in  peritoneum.  Liver  o^reatly  en- 
larged ;  weighed  161  oz.  ;  studded  with  cancerous  nodules,  many  of 
which  projected  from  surface.  Portal  vein  much  dilated,  and  on  tracino- 
it  into  liver  cancerous  masses  were  found  moulded  to  shape  of  veins 
and  branching  with  them,  but  not  adherent  to  their  walls.  Gall-duct 
pervious  ;  spleen,  17-|-  oz.,  contained  several  masses  of  cancer.  Eio-ht 
kidney  entirely  deslroyed,  being  simply  a  bag  of  soft  disintegrating 


2  24  EXLARGEMEXTS    OF    THE    LIVER.  lect.  vi. 

cancer.  Vessels  of  right  kidney  compi'essed  by  cancerous  nodules 
projecting  from  liver,  and  veins  extremely  dilated.  Left  kidney  mnch 
cnlaro-ed,  but  healthy;  stomach  and  pancreas  healthy.  Lungs  congested 
and  studded  with  cancerous  masses. 

The  next  case  to  Tvhicli  I  shall  direct  your  attention  was  re- 
markable not  only  for  the  early  age  of  the  patient  and  the 
rapid  course  of  the  malady,  but  more  particularly  for  the  py- 
rexia which  marked  its  course.  Little  is  known  as  to  the  range 
of  temperature  in  cancer.  Wunderlich  makes  the  following 
observations  upon  the  subject.  'It  is  a  peculiarity  of  cancer 
cases  that  elevated  temperatures  are  comparatively  rare,  and 
that  the  temperature  generally  maintains  itself  on  a  normal,  or 
even  subnormal,  plane,  which,  however,  by  no  means  precludes 
the  occurrence  of  high  temperatures  through  intercurrent 
complications,  or  at  the  close  of  the  disease.  But  fever  tem- 
peratures of  long  duration  are  at  least  rare  in  cancer  patients.' 
In  confirmation  of  this  opinion,  Dr.  Woodman,  the  translator 
of  Wunderlicli's  treatise,  quotes  cases  observed  by  Drs.  Finlay- 
son,  Da  Costa,  and  E.  B.  Baxter,  and  adds  :  '  The  few  obser- 
vations I  have  myself  made  of  carcinoma  of  the  liver,  uterus, 
and  breast,  before  marasmus  had  set  in.  only  show  very  slight 
elevations  of  temperature,  or  none  at  all ;  never  above  101°  Fahr. 
unless  from  some  complication  ;  whilst  I  have  found  subnormal 
temperatures  with  rapid  pulse  in  several  cases  of  advanced 
cancer  witli  emaciation.' ' 

My  own  experience  coincides  with  the  opinions  now  quoted, 
and,  I  believe,  with  those  of  most  observers,  viz. : — that  in  cancer, 
unless  there  be  some  inflammatory  complication,  the  bodily 
temnerature  is  at  or  about  the  normal  standard,^  and  accord- 
ino-ly  in  the  case  of  any  obscure  internal  disease,  a  continuous 
elevation  of  temperature  would  in  itself  be  opposed  to  the  dia- 
gnosis of  cancer.  But  the  case  now  related  proves  that  this 
rule  is  not  absolute.  In  this  case,  moreover,  the  age  of  the 
patient,  24,  was  opposed  to  cancer  of  the  liver ;  while  not  only 
the  pyrexia,  but  the  rigor,  the  previous  injury  and  enlargement 
of  the  testicle,  the  rapid  course,  and  the  cerebral  symptoms,  all 
favoured  the  diagnosis  of  pyajmic  inflammation,  in  preference 
to  cancer  of  the  liver. 

'  On  the  Tcmpcmturc  in  Discascp,  by  C.  A.  "Wiuulcrlicli,  Syd.  Soc.  Transl.  1871, 
pp.  429,  430. 

2  Since  this  case  occurred,  I  have  met  wiili  another  capp,  n  lady  aged  56,  with 
primary  uncomplicated  cancer  of  the  liver,  and  a  tcniiieratnre  of  102°. 


CAXCEE. 


--^5 


Case  XCI. — Acide  Cancer  of  Liver  tvitlt  Pyrexia  in  a  man  aged  24. 

James  C ,  24,  carpenter,  adm.  into  St.  Thomas's  Hospital  Nov. 

6,  1872.  No  history  of  malignant  disease  in  family,  and  previous 
health  good.  Six  months  before,  strained  himself  whilst  turning  a 
crane  ;  left  testicle  swelled  and  was- tender,  but  general  health  appeared 
unatFected.  Six  weeks  before  admission  first  complained  of  pain  in 
right  side  of  abdomen  and  began  to  lose  flesh  and  strength.  Soon 
after  a  doctor  discovered  a  swelling  in  right  hypochondrium,  which 
rapidly  increased.  Had  no  rigors,  but  twice  during  sleep  had  per- 
spired profusely. 

On  admission,  emaciated;  hectic  flush  on  cheeks  ;  temp.  101'o°  F. 
Suffered  much  from  pain  in  region  of  liver,  and  from  dyspnoea.  On 
right  side  of  abdomen  was  a  visible  bulging,  continuous  apparently 
with  liver,  its  lower  margin  extending  almost  to  brim  of  pelvis,  and 
upper  margin  of  hepatic  dulness  reaching  to  \\  iii.  below  nipple  ; 
surface  of  swelling  firm,  smooth,  and  moderately  tender.  Distinct 
jaundice  of  skin  and  conjunctivae ;  na  ascites  nor  enlargement  of  ab- 
dominal veins.  Tongue  moist,  slightly  furred ;  no  appetite  ;  much  thirst ; 
no  vomiting  ;  bowels  open  but  not  loose  ;  bile  in  stools.  Urine  1018  ; 
contained  copious  lithates,  some  bile-pigment,  and  a.  trace  of  albumen. 
Lay  on  right  side  ;  respirations  32,  thoracic  ;  some  cough,  but  no  ex- 
pectoration ;  sibilant  rales  over  both  lungs,  and  over  back  of  both  lungs, 
but  chiefly  on  right  side,  breath  sound  feeble  and  slight  impairment 
of  resonance  on  percussion.  Pulse  120  ;  heait's  sound  normal.  Left 
testicle  twice  size  of  right,  hard  but  not  tender. 

Patient  was  ordered  a  milk  diet  and  an  effervescing  saline  mix- 
ture. He  had  also  morphia  draughts  and  subcutaneous  injections  of 
morphia,  and  laudanum  poultices  to  relieve  pain,  but  he  got  rapidly 
worse.  Nov.  8.- — Pulse  134.  Vomited  last  night  a  greenish  flocculent 
matter  containing  no  food.  Nov.  11. — Has  repeatedly  vomited  green 
bilious  matter,  and  jaundice  is  now  very  decided.  Liver  increased  in 
size,  more  bulging  below  ribs,  and  its  dulness  extending  to  within 
\  in.  of  nipple ;  surface  smooth  and  firm.  Tongue  red  and  dry  ; 
bowels  open  daily.  Very  prostrate,  and  occasionally  delicious.  No 
rigors  or  night-sweats.  Pulse  120  ;  a  systohc  bruit  audible  at  base  of 
heart  and  propagated  upwards  to  clavicles  and  neck.  Nov.  13. — De- 
lirium, jaundice,  and  enlargement  of  liver  increased.  Swelling  below 
ribs  is  more  elastic,  but  there  is  no  distinct  fluctuation.  Yesterdtiv 
had  a  decided  rigor,  followed  by  heat  and  perspiration.  Nov.  lo. — 
Much  more  prostrate,  but  no  more  shivering.  Skin  dry.  Still  deli- 
rious.    Got  rapidly  weaker,  and  died  on  Nov.  IG. 

The  following  is  a  note  of  observations  of  the  temperature : — 


226 


Nov. 


ENLARGE 

MENTS    OP    THE    LIVE: 

I.                                  J.ECT.   VI 

Morning 

Evening 

6.           .         .         . 

— 

.     101'2 

7. 

.      1011 

.     103- 

8. 

.       99- 

.      101-4 

9. 

.       98o 

.      101-2 

10. 

.       9«- 

.      100- 

11. 

.     100- 

.      103- 

15. 

.       98-i 

Autopsy. — Liver  much  enlai-ged,  and  before  removal  measured  12^ 
in.  vertically.  Its  entire  substance  was  studded  witli  numerous  masses 
of  cancerous  deposit,  intensely  vascular,  and  varying  in  size  from  a 
pea  to  a  chestnut.  Many  of  them  were  at  the  surface  of  the  organ, batdid 
not  project  from  it.  The  cancerous  masses  were  not  softened.  On  section 
they  yielded  a  milky  juice  containing  numerous  cells  with  large  nuclei, 
such  as  are  common  in  cancer.  A  mass  of  similarly  affected  glands  was 
found  in  neighbourhood  of  left  kidney  and  extending  along  vessels  to 
left  testicle,  which  also  contained  a  vascular  tumour  of  size  of  a  cherry. 
Both  lungs  also  contained  numerous  tumours  similar  to  those  in  liver. 
No  sign  of  recent  inflammation  in  any  part  of  body.     Heart  healthy. 

The  chief  interest  in  the  following-  case  consists  in  the  fact 
that  a  lai^g-e  cyst  containing  bloody  fluid  was  developed  in  a 
cancerous  liver,  probably  from  obstruction  of  one  of  the  intra- 
hepatic ducts.  This  cyst  formed  a  prominent  tumour  above 
the  liver,  and  was  repeatedly  tapped  during  life,  to  relieve  dys- 
pnoea. Had  such  a  cyst  formed  in  the  early  stage  of  the  dis- 
ease, and  I  have  met  with,  a  case  Avhere  this  seemed  jjrobable, 
the  disease  might  have  been  mistaken  for  hydatid.  Here  the 
collateral  signs  pointed  unequivocally  to  cancer ;  and  the  only 
question  was  whether  the  collection  of  fluid  above  the  liver 
was  in  a  cyst  originating  in  the  'gland,  or  in  a  cavity  between 
the  liver  and  diaphragm  circumscribed  by  peritoneal  adhesions, 
as  may  sometimes  be  observed  in  connection  with  cirrhosis  &c. 
(See  Cases  XCIV.  and  CIX.) 


Case  XCII. — Cancer  of  Liver — Ascites  and  Jaundice — Large 
Cyst  projectiufj  from  upper  surface  of  Liver. 

On  Oct.  9,  1873,  Mr.  F ,  aged  51,  was  sent  for  my  advice  b}-  Dr 

Dobie  of  Chester.  He  had  lived  generously,  but  had  not  been  intem- 
perate. His  health  had  been  good  until  three  months  before,  Avlien  he 
began  to  have  pain  in  region  of  liver  and  in  right  shoulder,  and  since 
then  ho  had  sufi'crcd  from  loss  of  flesh  and  strength,  constipation  and 
fliitiileiice,  and  latterly  from  swelling  of  abdomen,  dyspna'a  on  exertion, 
and  cough. 

On  examination,  considerable  ascites  ;  girth  of  abdomen  42  in.  No 
oedema  of  legs.  No  decided  jaundice,  but  the  sallow  countenance  of  cir- 
rhosis. Dimensions  of  liver  could  not  be  made  out.    Pulse  108 ;  sounds 


LKCT.  Ti.  CANCER.  227 

of  heart  healthy.     Urine  dark  and  loaded  with  lifchates,  but  no  albu- 
men. 

He  was  treated  with  saline  purgatives  and  diuretics,  including 
chloride  of  ammonium,  digitalis,  and  blue  pill,  and  he  had  also  different 
preparations  of  iron.  At  first  there  was  considerable  improvement, 
ascites  diminished,  and  then  both  liver  and  spleen  appeared  to  be  con- 
siderably enlarged  and  liver  was  also  tender.  On  'Nov.  5  a  bulging, 
size  of  large  orange,  was  discovered  in  right  side  of  epigastrium,  evi- 
dently due  to  fluid  distinct  from  that  in  peritoneum.  This  swelling 
increased,  as  did  also  flatulence  and  dyspnoea  after  meals.  On]S"ov.  12 
liver  was  noted  as  larger,  and  nodulated  on  surface.  On  Nov.  13,  after 
dinner,  while  stooping  to  take  off  stockings,  was  seized  with  alarming 
dyspnoea  and  sent  for  me,  I  found  him  livid,  and  swelling  in  epigas- 
trinm  larger.  This  was  punctured  with  a  flne  trocar,  but  only  about 
two  drachms  of  bloody  flaky  serum  came  away.  This  contained 
numerous  cells  with  large  nuclei  (cancer- cells).  Gradually  dysj)ncea 
subsided,  and  on  Nov.  15  patient  was  able  to  return  to  Chester. 

On  Nov.  25  he  had  another  severe  attack  of  dyspnoea,  and  Dr. 
Dobie  drew  off  from  cyst  in  epigastrium  30  oz.  of  red  fluid,  of  specific 
gravity  1020,  and  containing  numerous  blood-corpuscles.  The  opera- 
tion was  followed  by  great  relief  to  the  breathing,  but  the  fluid  collected 
again,  and  on  Dec.  5,  47  oz.  were  drawn  off.  Ascites  also  increased, 
though  slowly;  pain  in  liver  persisted;  and  early  in  December  legs 
began  to  swell  and  intense  jaundice  set  in,  with  complete  anorexia. 
Patient  gradually  sank,  and  died  on  Jan.  1, 

Autopsy. — Eight  pints  of  turbid  yellow  serum  containing  flakes  of 
lymph  in  peritoneum.  Liver  greatly  enlarged,  and  both  lobes  exten- 
sively infiltrated  with  soft  cancer.  Projecting  from  convex  surface 
of  right  lobe,  and  evidently  originating  in  liver,  was  a  large  cyst  con- 
taining bloody  fluid  which  had  been  tapped  during  life.  No  enlarge- 
ment of  spleen ;  this  had  been  simulated  during  life  by  left  lobe  of 
liver  reaching  far  downwards  and  to  left.     Other  organs  healthy. 

The  preparation  which  I  now  show  you  was  removed  from 
the  body  of  a  patient  in  this  hospital  (Middlesex)  while  I  was 
pathologist,  and  was  exhibited  to  the  Pathological  Society 
(Trans,  vol.  xiii.  p.  100).  It  illustrates  a  rare  mode  of  fatal 
termination  of  cancer  of  the  liver.  ^ 

Case  XCIII.- — Frimanj  Cancer  of  Liver — Death  from  HcemorrJiaqe 

into  Peritoneum. 
Patrick  S— — ,  aged  50,  became  an  out-patient  at  Middlesex  Hos- 
pital, under  Dr.    Greenhow,  in  August  1861.     At  a  former  period  of 

'  For  additional  cases,  see  Frerichs,  Dis.  of  Liver,  Syd.  Soc.  Trans,  ii.  p.  333  ; 
Murchison,  Path.  Trans,  xiii.  p.  102;  also  Budd,  Dis.  of  Liver,  3rd  ed.  p.  396.  In 
Frerichs'  case,  the  hfemorrhage  seemed  to  commence  three  days  before  death,  and  the 
appearances  in  the  liver  were  very  similar  to  those  above  described. 

Q  2 


228  ENLAEGEMENTS    OF    THE    LIVER.  lrct.  vi. 

his  life  lie  had  been  very  intemperate,  and  he  had  been  in  the  habit  of 
drinking  a  large  quantity  of  spirits.  For  some  months  he  had  been 
losing  flesh,  and  he  had  been  suflfering  from  occasional  nausea  and 
other  dyspeptic  symptoms,  and  from  pains  in  epigastrium.  Dr.  Green- 
how  discovered  that  liver  was  enlarged  and  distinctly  nodulated  below 
marcrin  of  right  ribs,  and  recognised  the  peculiar  physiognomy  charac- 
teristic of  the  cancerous  cachexia.  There  was  no  jaundice,  and  little 
or  no  ascites  ;  and  nothing  was  observed  to  indicate  an  immediate  fatal 
termination. 

On  Aug.  26  the  patient  was  brought  to  hospital,  and  admitted 
under  Dr.  Goodfellow,  his  condition  having  become  suddenly  worse 
about  two  days  before.  His  symptoms  on  admission  were  great  pros- 
tration and  cachectic  countenance  ;  marked  jaundice  of  skin,  conjunc- 
tivae, and  urine  ;  complete  loss  of  appetite,  urgent  vomiting,  intense  pain 
and  tenderness  in  region  of  liver,  which  was  much  enlarged,  hard  and 
nodulated ;  abdomen  much  distended  and  fluctuating:  small,  rapid  pulse. 

ISTo  improvement  took  place ;  and  day  after  admission  patient 
vomited  a  large  quantity  of  dark  bloody-looking  fluid. 

During  night  of  27th  he  fell  into  a  state  of  collapse,  which  con- 
tinued until  death  at  2. BO  p.m.  of  August  28. 

Autopsi). — Moderate  emaciation  ;  marked  jaundiced  tint  of  conjunc- 
tivje  and  skin  and  of  tissues  generally,  including  the  internal  organs 
and  bones.  Between  five  and  six  quarts  of  dark-red  bloody  serum  in 
peritoneal  cavity,  and  lying  on  upper  surface  of  right  lobe  of  liver,  to- 
wards its  right  extremity,  between  it  and  diaphragm,  was  a  dark  coagu- 
lum  of  blood  which  weighed  5  oz.  avoirdupois.  Sei^ous  coat  of  in- 
testines, which  was  Viathed  by  the  bloody  fluid,  presented  no  abnormal 
injection  or  deposit  of  lymph.  Liver  weighed  72  oz. ;  right  lobe 
was  relatively  much  enlarged,  measuring  9  in.  transverselj',  while 
left  lobe  was  much  atrophied,  and  a  mere  appendage  to  right,  not 
exceeding  H  in-  in  its  transverse  diameter ;  greater  part  of  diminu- 
tive left  lobe  granular  on  surface,  and  pi-escnted  on  section  appearances 
characteristic  of  cirrhosis.  Corresponding  to  lobus  quadratus  was  a 
rounded  mass,  about  size  of  a  large  walnut,  attached  by  a  narrow 
pedicle,  and  likewise  composed  of  cirrhotic  glandular  tissue.  Whole 
surface  of  right  lobe  of  liver  covered  with  prominent  nodules,  varying 
in  size  fi-om  a  pea  to  a  large  cherry,  the  largest  being  very  clastic  or 
almost  fluctuating ;  they  were  most  developed  near  anterior  margin  of 
right  lobe  on  upper  surface.  The  coagulum  on  surface  of  right  lobe 
was  adherent  at  one  spot  near  right  extremity  of  organ,  corresponding 
to  one  of  softened  nodules,  which  was  ruptured.  The  sti-uctnre  of 
rifht  lobe  of  liver  was  extremely  dense ;  and  on  making  a  section,  it 
appeared  to  consist  of  two  abnormal  elements,  a  groundwork  of  firm 
grey  scirrhus-looking  tissue,  infiltrated  with  a  creamy  yellowish  juice, 
and  containing  a  number  of  cavities  up  to  size  of  a  cherry,  filled  with 
a  soft  pulpy  bright  yellow  substaiicc  ;   whole  of  right  lobe  appeared  to 


i.ECT.  VI.  CAiSTCEE.  229 

be  made  up  of  these  abnormal  elements,  and  scarcely  presented  at  any 
part  a  trace  of  natural  glandular  tissue  or  of  bile-ducts.  The  scirrhous 
structure  had  encroached  to  some  extent  along  anterior  margin  of  left 
lobe. 

On  examining  with  microscope  juice  scraped  from  denser  scirrhous 
portions,  it  was  found  to  contain  a  multitude  of  rounded,  elliptical,  and 
fusiform  cells,  up  to  J-^  of  an  inch  in  diameter,  with  one  or  sometimes 
two  large  nuclei  about  one-third  size  of  cell ;  many  of  cells,  likewise, 
included  brownish  pigment-granules.  In  softened  portions,  similar 
cells  were  discovered,  mixed  up  with  a  large  quantity  of  oily  and  pig- 
mentary matter,  both  inside  aiid  outside  cells. 

Other  abdominal  organs  normal.  Heai-t  normal.  Apices  of  both 
lungs  condensed  and  puckered,  and  contained  encysted  calcareous 
masses  up  to  size  of  a  pea. 

In  Case  XCIY.  the  immediate  cause  of  death  was  also  pro- 
bably liEemorrhage  into  the  peritoneum.  The  preparation 
which  I  show  you  appears  to  be  an  illustration  of  that  rare 
form  of  disease  described  by  Dr.  Bright  and  other  writers  as 
'  fungus  hsematodes  '  of  the  liver,  where  the  growth  projects 
greatly  from  the  general  surface  of  the  organ.  The  transition 
between  the  secreting  cells  of  the  liver  and  the  large  cells  of 
the  growth,  determined  by  myself  and  Dr.  Cayley,  is  likewise  a 
matter  of  considerable  pathological  interest. 

Case  XCIY. — Cancerotis  Ttcmour  (Fungus  Hcematodes),  projecting 
from  topper  siorface  of  Liver — Hrmnorrhage  into  Feritoneum. 

Luke  T- — • — ,  aged  57,  was  sent  to  London  Fever  Hospital  on  Jan. 
20,  1868,  supposed  to  be  suffering  from  '  fever.'  He  had  no  friends, 
and  could  give  no  account  1  if  his  previous  history.  On  admission  he 
had  a  heavy  .stupid  countenance,  and  his  mind  was  confused.  He  was 
very  emaciated  ;  pulse  varied  from  To  to  88,  and  was  very  weak. 
Tongue  dry  and  brown ;  bowels  rather  loose ;  abdomen  slightly  dis- 
tended, partly  from  tympanites,  but  partly  also  from  fluid  in  peritoneum. 
Hepatic  dulness  appeared  to  be  normal.  Occasional  coug-h,  with  thin 
frothy  expectoration ;  slight  dulness  over  both  lungs  posteriorly,  with 
rather  fine  crepitation,  but  no  tubular  breathing.  ISTo  night-sweats  ; 
neither  jaundice,  dropsy,  nor  albumen  in  urine. 

Patient  was  treated  with  ammonia,  and  subsequently  with  iron  and 
mineral  acids,  along  with  beef-tea,  milk,  and  brandy  ;  but  symjDtoms 
became  gradually  worse,  emaciation  and  ascites  increased ;  frequent 
low  muttering  delirium ;  and  on  Feb.  2  slight  jaundice,  but  motions 
still  contained  bile.  Pulse  rarely  exceeded  80.  Patient  became  every 
day  weaker,  but  no  fresh  symptom  of  importance  appeared.  He  died 
on  Feb.  16. 


230 


ENLAttGEMfijSrTS    OP   THE    LIVER. 


Autopsy. — Peritoneum  contained  between  three  and  four  quarts  of 
dark  sanguinolent  fluid.  Liver  was  separated  from  diaphragm  in  front 
and  from  anterior  abdominal  wall  for  2  or  3Jn.  by  a  space  filled  with 
this  sanguineous  fluid  ;  suspensory  ligament  elongated  in  a  correspond- 
ing degree.  Liver  weighed  64  02. ;  capsule  slightly  thickened  and 
opaque,  but  surface  smooth.  On  section  it  appeared  unusually  dense 
and  tenacious.  Projecting  from  upper  and  back  part  of  right  lobe  was 
a  rounded  tumour  as  big  as  a  man's  fist.  This  was  embedded  in  a 
hollow  in  diaphragm,  to  which  it  was  so  firmlj'  adherent  that  part  of 
it  was  left  behind  in  removing  liver.  This  tumour  was  of  pulpy  soft- 
ness, and  reflected  over  it  was  the  thickened  capsule  of  liver,  from 
inner  surface  of  which  the  pulpy  mass  could  be  easily  scraped  with 
handle  of  knife.  On  section  there  was  seen  to  be  a  sharp  line  of 
separation  between  it  and  the  deilse  tissue  of  the  rest  of  liver.  The 
pulpy  substance  was  torn  with  greatest  facility,  and  was  very  vascular, 
so  that  it  was  obviously  the  source  of  blood  in  peritoneum.  On  micro- 
scopic examination,  it  was  found  to  be  made  up  of  large  nucleated  cells, 
with  an  average  diameter  of  -^^^  inch,  or  about  three  times   that  of  a 


Fig.  19.  Shows  microscopic  appearances  of  tumour  of  liver  in  Case  XCIV.  a,  Large 
nucleated  cells  of  various  shapes,  and  some  ■with  a  douMe  nucleus  ;  /),  similar  cells 
containing  oil-glolmles  ;  c,  large  coll  containing  bile-pigment  ;  d,  cells  resembling 
in  every  respect  glandular  epithelium  of  liver ;  c,  transitional  forms  between  these 
last  cells  and  the  large  cells. 


hepatic  gland-cell.  The  cells  were  i-ounded,  pyriform,  or  caudate, 
and  each  contained  one  or  sometimes  two  nuclei,  with  much  fine 
granular  matter  ;  some  were  full  of  oil-globules,  and  some  contained 
brown  pigment-granules  exactly  like  wliat  is  seen  in  gland-colls  of 
liver.  Along  with  these  large  cells,  which  were  much  the  more 
numerous,  were  others  of  smaller  size,  and  not  to  be  distinguished  from, 
secreting  cells  found  in  other  parts  of  liver  (fig.  10). 

Stomach  and  intestines  healthy  ;  walls  of  heart  thin  and  soft ;  both 


LECT.  Yi,  CANCEE.  231 

lungs  firmly  adherent,  and  much  congested  in  dependent  parts.  No- 
thing noteworthy  in  any  other  organ. 

Case  XCV.  is  an  illustration  of  cancer  implicating  the  liver, 
without  producing  any  symptoms  or  signs  which  could  lead  to 
its  existence  being  suspected  during  life.  One  of  the  supra- 
renal capsules  also  was  destroyed  by  cancer^  and  yet  there  was 
no  vomiting  or  bronzing  of  the  skin.  It  is  now  well  known 
that  the  suprarenal  capsules  may  be  destroyed  by  cancer,  with- 
out any  of  the  symptoms  of  Addison's  disease  resulting,  so 
that  these  symptoms  must  be  ascribed,  not  so  much  to  the 
destruction  of  the  capsules,  as  to  the  morbid  process  by  which 
this  is  effected. 

Case  XCV. — Cancer  of  VertehrcB,  Suprarenal  Capsule,  Liver,  and 
Lung — No  symjptoms  of  Disease  of  Liver. 

Alfred  T ■,  aged  55,  admitted  into  Middlesex  Hosp.  under  my 

care,  Jan.  28,  1868.  He  was  very  weak  and  emaciated,  and  not  very 
connected  in  his  replies.  Seventeen  years  before  admission  he  con- 
tracted syphilis,  followed  by  constitutional  symptoms,  but  his  '  present 
attack  '  commenced  only  three  months  before  admission  with  severe 
pain  in  spine,  accompanied  by  emaciation  and  weakness. 

His  symptoms  while  under  observation  were  as  follows  : — Pro- 
gressive emaciation  and  debility,  and  angemic  chlorotic  colour  of  face  ; 
but  no  jaundice,  or  bronzing  of  skin,  or  discoloration  of  mucous  mem- 
brane of  mouth,  or  perspirations.  Persistent  pain  and  tenderness  on 
pressure  over  spinous  process  of  third  and  fourth  lumbar  vertebrae,  but 
no  sign  of  tumour  or  of  paraplegia,  excepting  retention  of  urine  for 
last  two  or  three  weeks  of  life.  Tongue  dry,  red,  and  fissured ;  no 
vomiting;  constipation  alternating  with  diarrhoea.  Abdomen  distended 
and  tympanitic,  with  slight  tenderness  on  deep  pressure  to  left  of  um- 
bilicus :  a  few  days  before  death  abdominal  swelling  subsided,  and 
aorta  could  be  felt  passing  along  spine,  but  no  appreciable  tumour. 
Hepatic  dulness  4  in.  in  r.  m.  1.  At  no  time  was  there  tenderness, 
or  a  feeling  of  nodulation  in  region  of  liver,  or  ascites.  Pulse  varied 
from  84  to  120,  always  small  and  weak  ;  cardiac  dulness  diminished  ; 
at  no  time  any  cough  or  expectoration,  and  at  time  of  admission  no 
notable  sign  of  mischief  could  be  discovered  in  lungs.  Urine  alkaline, 
and  contained  phosphates,  but  no  albumen  or  bile-pigment.  Tempera- 
ture either  normal,  or  but  slightly  increased.  Throughout  mind  was 
confused,  and  there  was  a  tendency  to  low  muttering  delirium,  increas- 
ing towards  death,  which  occurred  on  March  22. 

Autopsy. — A  soft  cancerous  tumour  of  bodies  of  third  and  fourth 
lumbar  vertebrse,  projecting  about  half  an  inch  from  surface,  chiefly  on 
left  side,  where  it  invaded  texture  of  psoas  muscle,  and  encroaching 
about  half-way  to  the  spinal  canal,  which,  as  well  as  the  spinous  pro- 


232  ENLARGEMENTS    OF    THE    LIVER.  lfxt.  vi. 

cesses,  appeared  normal.  Cancerous  enlargement  of  lumbar  and  bron- 
chial glands,  and  a  mass  'of  soft -cancer-,  size  of  a  large  walnut,  com- 
pressing a  large  branch  of  pulmonaiy  artery  in  upper  part  of  lower 
lobe  of  right  lung.  Liver  not  enlarged,  and  its  lower  margin  did 
iiot  project  beyond  edge  of 'ribs,  but  it  contained  from  a  dozen  to  twent}^ 
isolated  cancerous  nodules,  from  size  of  a  pea  to  that  of  a  walnut, 
several  of  which  were  excavated  in  centre.  One  of  these  nodules  was 
in  a  portion  of  liver  which  was  firml}-  adherent  to  right  supi'arenal 
capsule;  latter  organ  greatly  enlarged,  and  converted  into  amass  of 
hard  cancer,  measuring  -2:^  in.  in  diameter.  Left  capsule,  kidneys, 
and  brain  presented  nothing  abnormal. 

The  following  case  eame  under  my  notice  while  I  was  House 
Snrg-eon  in  the  Edinburgh  Royal  Infirmary.  It  is  an  example  of 
a  rare  form  of  cancer  implicating  the  liver,  but  causing  no 
symptoms  of  hepatic  disease. 

Case  XCVL — Melanotic  Cancer  of  Fenis,  Lyvriiliatic  Glands,  Liver, 

Pleura,  etc. 

James  L ,  aged  54,  a  butler,  was  admitted  into  Royal  Infirmary, 

Kdinburgh,  on  Feb.  4,  1851.  He  was  a  tall,  robust  man  ;  hair  was 
dark  brown,  and  eyeballs  were  remarkable  for  their  prominence,  and 
for  a  bluish  tint  of  sclerotics.  Attacl^ed  to  lowerand  onter  surface 
of  prepuce,  and  extending  a  considerable  way  along  its  free  margin, 
was  a  tumour,  size  of  a  chestnut,  of  a  dark  brown,  almost  black 
colour,  its  surface  nodulated  and  covered  with  a  fetid,  dirty  yellow, 
puriform  discharge.  When  pricked  with  a  pin,  it  bled  profusely,  and 
it  was  often  the  seat  of  acute  paiii,  especially  during,  and  for  a  short 
time  after,  micturition.  It  had  been  growing  for  two  years,  and  had 
(;onimenced  as  a  small  black  wart  on  the  outer  surface  of  prepuce, 
about  an  inch  from  its  i'ree  margin ;  this  wart  for  six  months  remained 
stationary,  but  afterwards  increased  more  rapidly.  On  I'efiecting  pre- 
puce, which  was  done  with  some  difficulty,  there  were  displayed  on 
surface  of  glans  several  warty  excrescences  of  a  bluish-black  colour, 
and  varying  in  size  from  a  pin's  head  to  half  a  pea.  In  each  groin  was 
a  swelling  of  size  of  a  hen's  Ggg,  which  had  first  appeared  about 
three  months  before  admission. 

For  three  months  patient  had  complained  of  dyspnoea  and  cough  ; 
and  on  examining  chest,  left  side  presented  a  uniform  bulging, 
measuring  fully  1  in.  more  in  circumference  than  right ;  there  was 
also  on  this  side  marked  dulness  (m  percussion,  imperfect  expansion, 
and  absence  of  respiratory  murmur  and  of  vocal  thrill.  Apex  of 
heart  displaced  to  left  margin  of  sternum.  Physical  signs  of  right 
lung  normal.     Pulse  00,  very  feeble. 

After  this,  patient  got  rapidly  worse  ;  he  lost  all  reli.sh  for  food,  and 
became  very  prostrate.     The  tits  of  dyspnoea  increased  in  frequency 


i.ECT.  VI.  CAKCER.  233 

and  in  severity,  lasting  sometimes  for  several  liours,  and.  dulness  "with 
-suppression  of  respiratory  murmur  was  observed  over  base  of  right 
lung.  Tumour  on  penis  and  swellings  in  groins  increased  slightly  in 
size.     'No  jaundice,  ascites,  or  enlargement  or  pain  of  liver. 

On  morniug  of  March  26  he  had  an  unusually  severe  attack  of 
dyspnoea  ;  pulse  84,  and  almost  imperceptible ;  extremities  cold  ;  face 
livid  and  eyeballs  more  prominent.  These  symptoms  continued  until 
death  on  evening  of  27th. 

Autopsy. — Tumour  on  perils  presented  on  section  a  smooth  black 
surface,  yielding  on  sectioia  a,  copious  inky  juice.  Lumbar,  inguinal, 
and  femoral  glands  enlarged  -and  infiltrated  with  black  matter ;  and 
some  of  them  entirely  converted  into  a  pulpy  black  fluid.  Lymphatics 
of  spermatic  cord  contained  one  or  two  small  melanotic  nodules. 
Along  whole  of  abdominal  aorta  w^as  a  chain  of  enlarged  glands.  Some 
of  these  exhibited,  on  section,  a  black  pulpy  mass  ;  while  others,  which 
were  but  slightly  enlarged,  presented  normal  glandular  structure,  with 
circumscribed  brownish-black  points.  Hypogastric  and  sacral  lym- 
phatics normal. 

Left  pleura  distended  with  several  quarts  of  fluid  tinged  with 
blood  and  black  pigment,  which  pushed  apex  of  heart  towards  right 
side.  Scattered  over  whole  of  parietal  and  pulmonaiy  pleura  were 
masses  of  a  dark  deposit,  varying  in  size  from  smallest  appreciable 
point  to  half  an  inch  in  diameter,  and,  for  most  part,  presenting  a 
circular  outline  ;  largest  of  these  nodules  projected  about  one-sixth  of 
an  inch  from  surface  of  pleura ;  smallest  were  not  appreciably  elevated, 
presenting  a  punctiform  appearance  not  unlike  shading  of  a  chalk 
drawing.  The  large  nodules  were  almost  black,  while  punctiform  de- 
posit had  a  brownish-black  tint,  tinged  more  or  less  with  purple.  Most 
of  nodules  were  covered  by  ej)ithelial  layer  of  pleura,  but  at  back  part 
of  cavity,  where  they  were  confluent  and  aggregated  into  flattened 
masses,  this  membranous  lining  was  at  some  places  wanting,  and  masses 
exhibited  a  pulpj  irregular  surface,  and  yielded  on  pressure  a  large 
quantity  of  dark  juice  very  like  liquid  sepia.  Left  lung  com- 
pressed and  carnified  ;  at  reflection  of  'pleura  from  root  of  lung  upon 
ribs  was  a  layer  of  recently  extravasated  blood,  at  some  parts  half  an 
inch  in  thickness.  Right  .pleura  contained  a  few  ounces  of  fluid  simi- 
lar to  that  in  left ;  and  its  surfa<;e  exhibited  nodules  of  deposit  of  same 
character,  but  less  extensive.  Embedded  in  substaaice  of  right  lung 
were  a  few  circumscribed  black  nodules,  the  largest  about  size  of  a 
cherry :  around  them,  pulmonary  tissue  was  normal  and  crepitant. 
Bronchial  glands  were  all  black,  but  not  much  enlarged  ;  in  posterior 
mediastinum  glands  were  greatly  enlarged,  and  a  cluster  of  them, 
forming  a  mass,  size  of  an  orange,  was  situated  in  angle  of  bifurcation 
of  trachea,  in  front  of  oesophagus ;  deep  cervical  glands  contained 
black  pigment. 

Between  mucous  and  muscular  coats  of  oesophagus  were  one  or 


234  ENLAEGEMENTS    OP   THE    LIVEE.  lect.  ti. 

two  rounded  nodules,  size  of  a  barley-corn,  containing  black  pigment ; 
rest  of  alimentary  canal  and  mesenteric  glands  normal.  On  surface 
of  liver  were  seen  about  a  dozen  nodules  of  black  deposit,  about  one- 
third  of  an  inch  in  diameter ;  numerous  similar  masses  embedded  in 
substance  of  organ,  which  was  but  slightly  increased  in  size.  In  spleen 
"was  a  single  mass  of  black  deposit,  size  of  a  pea.  Kidneys  contained 
in  cortical  substance  several  melanotic  nodules,  size  of  a  swan-shot. 
Between  muscular  and  mucous  coats  of  bladder  and  of  urethra  were 
a  few  black  nodules,  size  of  barleycorns. 

Gltemical  Examination  of  Melanotic  Matter. — The  following  analysis 
of  the  pigmentary  matter  was  raade  by  the  late  Dr.  James  Drum- 
raond  : — 

'  It  was  insoluble  in  water,  alcohol,  and  ether.  When  treated  with 
hydrochloric,  nitric,  and  sulphuric  acids,  it  was  dissolved  ;  the  solution 
being  nearly  colourless.  When  chlorine  gas  was  passed  through  it 
suspended  in  water,  it  was  bleached  to  a  certain  extent,  bat  not  entirely. 
When  boiled  with  potash,  it  dissolved,  with  disengagement  of  ammonia. 
The  ultimate  analysis  yielded  the  following  result: — 

Carbon 6701 

Hydrogen    ..........  6'4-o 

Nitrogen     .......>-.         11'45 

Oxygen ,.  8-36 

Ash 6-73 

100-00 

'The  ash  consisted,  in  great  part,  of  peroxide  of  iron.' 
Microscopic  Exatnination  of  Melanotic  Matter. — The  dark  juice 
from  tumour  on  penis  contained  a  large  quantity  of  gra»nular  matter  of 
a  sienna-brown  colour  ;  granules  were  solid  and  angular,  and  refracted 
light  strongly ;  acetic  acid  produced  no  change  upon  them,  but  strong 
nitric  acid  rendered  them  much  lighter.  Mixed  up  with  these  granules 
were  a  few  nucleated  cells,  having  a  circular  or  oval  outline,  and  a 
diameter  of  about  ^J-jj  of  an  inch.  Some  of  cells  were  more  elongated, 
and  one  or  two  exhibited  a  caudate  appearance.  Most  of  them  were 
loaded  with  coloured  granules,  which  quite  obscured  all  appearance  of 
a  nucleus.  In  some  of  cells,  however,  which  contained  little  or  none 
of  coloured  granules,  one  and  sometimes  two  nuclei  could  be  detected, 
with  one  or  two  distinct  nucleoli.  When  a  small  particle  of  tumour 
was  torn  out  with  needles  and  examined,  it  exhibited  a  network  of 
fine  filamentous  tissue,  infiltrated  through  meshes  of  which  were  the 
elements  of  the  dark-coloured  juice  just  described.  The  melanotic 
deposits  in  pleura  and  in  lumbar  and  inguinal  glands  were  subjected 
to  careful  microscopic  examination,  and  were  all  found  to  possess  a 
structure  similar  to  that  of  tumour  on  penis. 


235 


LECTURE  VII. 

i^NLAROEMENTS   OF  THE  LlVEIt. 

SPINDLE  -  CELL      SARCOMA  —  MYXOMA EPITHELIOMA CYSTO-SARCOMA MULTILOCULAK 

HYDATID — SIMPLE    CYSTS — TUBERCLE — LYMPHATIC     GROWTHS ENLARGEMENT     WITH 

XANTHELASMA — ENLARGEMENTS    OF    GALL-BLADDER. 

Gentlemen, — In  this  lecture  I  purpose  to  bring-  under  your 
notice  certain  diseases  which  occasionally  lead  to  enlargement 
of  the  liver,  but  which  are  of  comparatively  rare  occurrence, 
and  as  to  the  clinical  history  and  diagnostic  characters  of  which 
our  knowledge  is  as  yet  imperfect. 

XII.    SPINDLE-CELL    SAECOMA    OP    THE    LIVER. 

•5* 

The  following  case  is  an  example  of  a  form  of  enlargement 
of  the  liver  hitherto  (1873  ^)  undescribed.  It  illustrates  the  im- 
portance, on  clinical  grounds,  of  distinguishing  the  anatomical 
characters  of  the  different  lesions  still  too  commonly  grouped 
under  the  common  designation  of  '  cancer.'  Until  within  the 
last  few  years,  the  disease  in  this  case  would,  from  a  structural 
point  of  view,  have  been  regarded  as  a  variety  of  cancer. 
Structurally,  it  is  now  acknowledged  by  pathologists  to  be  dis- 
tinct from  cancer,  while  it  will  be  seen  that  the  clinical  history 
of  the  patient  was  very  different  from  that  of  true  cancer  of 
the  liver.  1.  There  was  no  evidence  of  the  so-called  cancerous 
cachexia.  The  patient  had  never  the  appearance  of  a  man 
suffering  from  malignant  disease  ;  four  months  before  his  death 
his  weight  was  exactly  the  same  as  it  had  been  twelve  months 
before,  although  all  this  time  the  disease  in  the  liver  had  been 
progressing;  and  he  continued  to  go  about  and  follow  his 
employment  until  within  two  or  three  weeks  of  his  death, 
the  cause  of  which  was  obscure.  2.  Cons.idering  the  size  of 
the  tumour,  there  was  much  less  pain  than  might  have  been 
expected  on  the  supposition  that  the  disease  was  true  cancer. 

*  The  case  was  communieated  to  the  Pathological  Society,  Jan,  21,  1873. 


236  ENLARGEMENTS    OP    THE    LIVER.  lect.  vii. 

The  severe,  but  rare  and  transient,  attacks  of  pain  in  the  right 
side  were  more  like  what  might  have  been  expected  to  result 
from  the  calculus  found  after  death  in  the  right  kidney,  than 
from  the  disease  in  the  liver.  For  a  time  a  burning  pain  was 
complained  of  in  the  liver,  but  for  many  months  before  death 
this  had  quite  ceased,  and  latterly  the  chief  complaint  was  a 
feeling  of  tightness  due  to  the  size  of  the  tumour.  3.  There 
was  neither  jaundice  nor  ascites.  4.  The  similarity  in  structure 
between  the  tumour  of  the  eyeball  and  that  of  the  liver 
pointed  to  a  constitutional  origin;  but  the  interval  between  the 
primary  and  secondary  lesion  was  much  greater  than  in  true 
cancer,  unless  Ave  are  to  suppose,  what  would  have  been  equally 
incompatible  with  cancer,  that  the  disease  had  been  going  on 
in  the  liver  for  eight  or  nine  years,  without  giving  rise  to  sym- 
ptoms, until  it  produced  an  appreciable  tumour.  5.  Primary 
cancer  of  the  liver  is  not  common  at  so  early  an  age  as  that  of 
my  patient.  It  remains  to  be  seen  whether  these  clinical 
characters  will  hold  good  in  other  cases  of  tumour  of  the  liver 
presenting  the  same  anatomical  structure. 

It  is  to  be  regretted  that  the  post-mortem  examination  was 
far  from  being  comj^lete,  and  in  particular  that  it  failed  to 
account  for  the  patient's  somewhat  sudden  death. 

Case  XCVII. — Sfindle-cell  Sarcoma  of  Liver. 

Mr.  L.  N ,  aged  30,  firs^t  consulted  me  at  my  house   on   Oct. 

9,  1871.  He  stated  that  18  iiioutlis  before  he  had  been  attacked  with 
a  sliarp  pain  between  right  ribs  and  iHum.  The  paiu  came  on  in  severe 
paroxysms,  but  after  two  days  it  ceased  ;  it  was  not  attended  by  vomit- 
ing, nor  followed  by  jaundice.  Nine  months  afterwards  he  had  a  second 
similar  attack  of  about  the  same  duration.  For  two  months  he  had  been 
losing  flesh,  but  not  to  a  great  extent,  and  one  month  before  he  came  to 
me  Dr.  Brown  of  Whitchurch  had  found  the  liver  to  be  considerably 
enlarged,  and  in  the  interval  this  enlargement  had  much  increased.  He 
was  a  man  of  very  temperate  habits,  and  had  never  had  syphilis.  On 
examination,  I  found  a  tumour  filling  the  right  side  of  abdomen  to 
within  two  inches  of  pubes,  continuous  upwai'ds  with  liver,  percussion 
dulncss  of  which  ascended  as  high  as  nipple  in  front,  but  not  too  high 
behind.  Behind  tumour,  in  both  flanks,  there  was  tympanitic  per- 
cussion sound.  The  tumour  formed  a  perceptible  prominence  in  right 
side  of  abdomen,  and  right  lower  ribs  bulged  out  considerably.  At 
umbilicus  girth  of  right  side  of  abdomen  was  10^  in.,  and  of  left,  15|  in., 
and  girth  of  chest,  2  in.  below  nipple,  was  17  in.  on  right  side,  and  16^^ 
in.  on  left.     Tlie  surface  of  the  tumour  was  uneven  from  the  presence 


LECT.  vii.  RPINDLE-CELL    SARCOMA.  237 

of  several  semi-globular  elevations  ;  its  consistence   was   doughy,  es- 
pecially over  most  prominent  parts,  but  tbere  was  nowhere  any  feeling 
of  fluctnation,  vibration,  or  elasticity,  or  any  tenderness  on  pressure. 
The  patient  complained  of  a  frequent  burning  pain  in  tumour,  which 
often  kept  him  awake  at  night,  and  of  a  feeling  of  weight  after  meals  ; 
bnt  he  did  not  suffer  from  nausea  or  vomiting;  his  appetite  was  good, 
and  bowels  regular,  and  he  had  not  lost  strength.     He  could  walk  five 
or  six  miles  a  day  without  fatigue.     Urine  deposited  a  copious  sedi- 
ment of  lithates,  and  became  almost  black  on  addition  of  nitric   acid 
after    boiling ;    but   it    contained   no   albumen,    nor    did    it    exhibit 
ordinary  reaction  of  bile-pigment  with  nitric  acid.     Heart  was  pushed 
up,  its  apex  being  felt  between  fourth  and  fifth  ribs,  just  below  nipple. 
An  opinion  had  already  been  expressed  by  several  physicians  who 
had  been  consulted  that  the  tumour  was  hydatid,  but  this  view  was 
negatived  by  : — 1.  The  absence  of  any  fluctuation  or  elasticity  in  the 
prominences  on  its  surface;  2.  Its  rapid  growth  ;  3.  The  burning  pain  ; 
and,  4.  The  patient's  statement  that  on  April  2,  1862,  his  left  eyeball 
had  been  excised  by  Mr.  Hulke  for  what  had  been  called  '  a  malio-nant 
tumour.'     On  the  other  hand,  it  seemed  clear  from  its  consistence  that 
if  the  tumour  was  cancer  it  must  be  a  rapidly-growing  soft  cancer,  and 
this  view  was  negatived  by  : — 1 .  The  healthy  appearance  and  strength 
of  the  patient;  2.  His  good  appetite  and  but  slightly  impaired  digestion  ; 
3.  His  family  history.     His  father  and  mother  were  both  alive  and  well, 
and  no  member  of  his  family  had  suffered  from  cancer ;  4.  His  age ;  6.  The 
long  interval  of  good  health  between  excision    of  eyeball   and   com- 
mencement of  disease  in  liver.     The  opinion  given  to  the  patient  was 
ihat  the  tumour  was  something  more  solid  than  hydatid,  and  that  no 
benefit  would  be  derived  from  paracentesis.     As  the  tumour  appeared 
to  be   of  an  unusual  nature,  I  wrote  to   Mr.   Hulke  to  ascertain  the 
nature    of  growth  in   eyeball   removed  in   1862.     N"ot  regarding  my 
opinion  as  satisfactory,  the   patient  went  on  the  same  day  to  Sir  W. 
Gull,  whose  opinion  was  that  the  tumour  was   not  hydatid,  and  pro- 
bably cancer.     By  the  same  post  which  brought  my  letter,  Mr.  Hulke 
received  another  from  Sir  W.  Gull,  making  a  similar  enquiry. 

Mr.  Hulke  had  fortunately  preserved  copious  notes  and  microscopic 
drawings  of  tumour  in  eyeball.  For  two  years  before  patient  had 
consulted  him  in  March  1862  there  had  been  a  progressive  decrease  of 
the  visual  field  in  left  eye,  and  for  three  months  complete  loss  of  sight. 
At  first  there  had  been  no  external  signs,  but  for  one  month  there  had 
been  redness  and  oedema  of  the  conjunctivae  and  intense  pain.  On 
consulting  Mr.  Hulke  the  man  looked  healthy,  except  that  left  eyeball 
was  distended  and  hard,  and  pupil  widely  dilated  and  motionless ;  iris 
was  discoloured  and  pushed  forwards,  and  at  temporal  side  of  fundus  oculi 
could  be  seen  a  solid  buff-coloured  tumour,  advancing  nearly  to  lens,  and 
covered  by  retina  and  choroid.  After  enucleation,  a  tumour  was 
found  in  the  choi'oid  in  the  situation  observed  during  life.     It  was 


238  ENLARGEMENTS    OF    THE    LIVER.  lkct.  vii 

greyisli,  and  on  section  there  exuded  a  viscid  yellowish,  rather  than  a 
creamy  juice.  It  consisted  mainly  of  small  fusiform  nucleated  fibre- 
eells  (fig.  20),  the  prolongations  of  which  were  woven  into  a  tangled 
web,  whose  meshes  w^ere  filled  with  a  hyaline  albuminoid  matrix. 
Mr.  Hulke  added  that  in  accordance  with  the  views  then  held,  the  tumour 
was  called  a  medullary  cancer,  but  that  '  its  structui-e  was  character- 
istic of  what  vpe  now%  in  Virehow's  terms,  call  a  spindle-cell  sarcoma.' 
The  man  made  a  rapid  recovery,  and  there  was  never  any  return  of 
tumour  in  the  cicatrix. 

On  obtaining  this  information,  I  wrote  to  the  patient's  medical 
attendant.  Dr.  Brown  of  Wliitchnrch,  expressing  the  opinion  that  the 
tumour  of  liver,  like  that  of  eyeball,  was  probably  a  spindle-cell  sar- 
coma, and  that  the  case  was  one  of  nnusual  interest. 

The  patient  continued  to  follow  his  employment  as  an  upholsterei', 
and  I  heard  nothing  more  of  him  until  June  10,  1872,  when  he  again 
came  to  London  to  consult  me.  The  tumour  had  increased  in  size, 
girth  at  umbilicus  being  34  instead  of  32  in.,  and  upper  margin  of  hepatic 
dulness  in  front  having  risen  to  above  nipple.  It  extended  across 
middle  line  as  far  as  left  lumbar  region.  At  many  places,  es- 
pecially those  which  were  most  prominent,  it  felt  much  more  tense 
and  elastic  than  it  had  done  previously,  but  nowhere  was  there  any 
distinct  fluctuation  or  vibration.  In  beginning  of  April  patient  had 
experienced  a  third  attack  of  severe  spasmodic  pain  below  right  ribs, 
but  this  had  ceased  after  the  use  of  chloral  and  subcutaneous  injections 


Fig.  20.    Group  of  spindle-cells  from  tumour  of  choroid,  x  240.     From  a  drawing  by 

Mr.  Ilulke. 

of  morphia.  He  was  now  also  free  from  the  burning  pain  of  which 
he  had  complained  eight  mouths  before.  As  long  as  he  was  quiet  he 
had  no  pain  whatever,  but  when  he  moved  much,  or  stooped  in  his 
])usiness,  he  had  a  good  deal  of  pain  below  right  ribs.  He  also 
suffered  from  dyspnoea  on  exertion,  and  a  feeling  of  fulness  after  meals. 
At  the  same  time  patient  did  not  look  anj^  worse  than  when  I  had  first  seen 
him,  and  his  weight  was  exactl}'^  the  same  as  it  had  been  twelve  months 
before.  His  tongue  was  cloiin  and  appetite  good  ;  no  jaundice,  no  as- 
cites, and  no  enl:irg(!ment  of  abdominal  veins.  He  was  still  following 
his  business,  and  he  could  walk  an  hour  without  fatigue. 

Although    the  circumstances  of  the  case  now  pointed  somcAvhat 
more  to  hydatid,  the  same  opinion  was  expressed  to  patient  as  before  ; 


LECT.  vii.  SPINDLE-CELL    SAECOMA.  239 

but  as  he  was  very  desirous  to  have  something  done,  he  was  told  that  no 
harm  could  result  fi'om  an  exploratory  puncture,  which  would  remove 
all  doubt  on  the  matter.  I  advised,  however,  that  he  should  previously 
have  the  advantage  of  a  consultation  with  Sir  W.  Jenner,  who  accord- 
ingly saw  the  patient  with  me  on  June  12,  and  who  concurred  in  the 
difficulties  of  the  case,  and  in  the  advisability  of  solving  them  by  para- 
centesis. A  small  trocar  was  accordingly  introduced  into  the  most 
elastic  portion  of  the  tumour  below  right  ribs ;  only  a  few  drops  of 
blood  came  away,  which  exhibited  nothing  but  blood- corpuscles  under 
microscope.  'No  bad  effect  followed  puncture,  and  in  a  few  days 
patient  returned  to  his  home  and  resumed  his  business,  which  he  con- 
tinued to  follow  until  Oct.  8,  the  tumour  slowly  increasing.  On  Oct.  8 
he  had  a  severe  attack  of  spasmodic  pain  over  whole  surface  of  tumour, 
which  was  relieved  by  application  of  hot- water  bags  and  repeated  doses 
of  hydrate  of  chloral.  He  continued,  however,  to  suffer  from  a  feeling  of 
tightness,  due  to  presence  of  the  tumour,  and,  experiencing  no  relief,  he 
left  his  home  on  Oct.  16  to  try  the  effect  of  hydropathy.  He  had 
throughout  his  illness  consulted  a  great  many  medical  men,  both  in 
London  and  in  the  provinces,  and  even  taken  the  opinion  of  a  female 
clairvoyante  respecting  his  case.  On  Oct.  25  he  died  at  the 
Turkish  Baths,  Bristol.  All  that  I  could  learn  of  the  symptoms  which 
preceded  death  was  that  for  36  hours  before  he  had  suffered  from  in- 
tense pain  over  the  tumour  to  right  of  the  umbilicus,  which  was  some- 
what relieved  by  subcutaneous  injections  of  morphia.  The  pain  was 
unattended  by  vomiting. 

The  body  was  examined  by  Dr.  T.  D.  ISTicholson,  of  the  Turkish 
Bath  establishment,  Bristol,  to  whom  I  am  indebted  for  the  following' 
particulars,  and  for  sending  to  me  portions  of  the  diseased  structures 
for  examination. 

The  peritoneum  was  adherent  at  several  places  to  surface  of  en- 
larged liver,  but  there  was  no  recent  lymph.     Projecting  from  anterior 


AND       MASSES 

CF      TUMOUR 


Fig.  21.     Sho^u's  tumours  projecting  from  liver.     From  a  sketch  by  Dr.  Nicholson. 

surface  of  each  lobe  of  liver  was  a  rounded  soft,  apparently  cystic 
tumour,  about  2  in.  in  diameter,  and  pressing  against  the  abdominal 
wall.  Projecting  from  under  surface  of  liver,  and  intimately  connected 
with  it,  was  an  enormous  mass  of  morbid  structure,  composed  of  cyst- 


240 


ENLARGEMENTS    OP    THE    LIVEE. 


I.ECT.   vir. 


like  bodies,  varying  in  size  from  that  of  a  cherry  to  that  of  a  child's 
head  (tig.  21).  This  mass,  together  with  the  liver,  weighed  20  lbs.  and 
1  oz.  avoird.  The  contents  of  the  small  tumours  on  upper  surface  of 
liver  were  dark  grey  and  gelatinous ;  those  of  the  large  masses  on 
under  surface  were  of  lighter  colour  and  of  pultaceous  consistence. 
Some  of  lumbar  glands  were  as  large  as  beans,  and  contained  a  soft 
grey  material.  Spleen  and  kidneys  were  healthy,  except  that  right 
kidney  contained  a  dark  rough  calculus  about  size  of  half  a  walnut. 
Heart  and  lungs  were  normal. 

The  portions  of  the  tumour  forwarded  to  me  were  submitted  to  Mr. 
Henry  Arnott  for  microscopic  examination.     After  hardening  in  a  solii- 


l^'ig.  22.     E'.'prescnts  a  section  of  the  ffrovtli  Iroin  the  liver,  x  220.     I'rom  a  drawiiifj 
liy  Mr.  Henry  Arnott. 

tion  of  chromic  acid,  the  gelatinous  material  of  which  the  tumours  were 
composed  was  found  to  be  a  typical  example  of  spindle-cell  sarcoma, 
as  will  be  seen  by  the  annexed  drawing  by  Islv.  Arnott  (fig.  22). 


XIII.    MYXOMA    OP    THE    LIVEE. 

The  clinical  characters  of  this  orrowth  in  the  liver  are  not 
yet  sufficiently  known.  Mr.  Nunn  has  recorded  a  case  in  which 
a  tumour  of  this  nature,  as  large  as  a  foetal  head  of  the  full 
period,  occupied  the  posterior  part  of  the  right  lobe  of  the  liver 
and  projected  from  its  upper  surface,  where  it  Avas  closely  ad- 
lierent  to  the  under  surface  of  the  diaphragm.  Tlie  patient  was 
a  female  aged  38,  Avho  within  twelve  months  of  lier  death  had 
been  twice  operated  upon  for  a  recurrent  niyxom.a  of  the 
breast.' 

'  Path.  Trans.  1872,  vol.  xxiv.  i'.  120. 


LECT.  vn.  SPINDLE-CELL    SARCOMA.  24 1 

XIV.    EPITHELIOMA    OF    THE    LIVER. 

In  the  25th  volume  of  the  '  Pathological  Transactions,'  Dr. 
Greenfield  has  described  a  case  of  primary  columnar  epithelioma 
of  the  liver.  The  patient  was  a  female  aged  33,  whose  clinical 
history  was  identical  Avith  that  of  cancer.  It  is  not  improbable 
that  in  many  cases  of  '  cancer '  of  the  liver  the  new  growth  has 
a  similar  anatomical  structure. 

XV.    CTSTOSARCOMA    OP    THE    LIVER. 

Naunyn  has  recorded  a  case  in  which  the  liver  was  found 
studded  with  small  tumours  having  a  structure  similar  to  that 
of  Cystosarcoma  of  the  mamma.  The  liver,  which  was  of  normal 
size  and  shape,  was  obtained  from  the  body  of  a  female  aged  62, 
who  had  been  for  a  long  time  under  the  care  of  Professor 
Prerichs  and  whose  chief  symptom  was  marasmus.' 

XVI.    MULTILOCULAR    OR    ALVEOLAR    HYDATID    TUMOUR. 

This  is  a  very  rare  form'  of  tumour  ;  only  about  eighteen 
cases  have  been  recorded,  not  one  of  which  has  occurred  in  this 
country.  It  is  composed  of  numerous  minute  hydatids  contained 
in  cavities  interspersed  through  a  hard,  almost  cartilaginous, 
matrix  of  fibrous"  tissue,  and  not,  as  in  the  case  of  an  ordinary 
hydatid,  enveloped  in  a  parent  cyst.  Its  clinical  characters  are 
very  different  from  those  of  an  ordinary  hydatid  tumour  of  the 
liver.  It  forms  a  rounded  tumour,  varying  in  size  from  that  ol- 
a  hen's  egg'  to  twice  that  of  a  man's  head,  and  in  most  cases  is 
situated  in  the  right  lobe.  When  small  and  deeply  seated  it 
may  be  inappreciable  during  life.  In  most  cases  it  can  be  felt 
or  it  causes  a  distinct  bulging.  The  tumour  is  not  smooth 
elastic,  fluctuating,  and  painless,  but  nodulated,  hard,  of  even 
cartilaginous  consistence,  and  tender.  In  almost  all  cases  there 
is  considerable  enlargement  of  the  spleen,  and  early  supervenino- 
intense  jaundice.  Ascites  is  somewhat  less  common  than 
jaundice,  and  in  many  cases  there  is  oedema  of  the  legs  in  the 
advanced  stage.  Progressive  emaciation  and  prostration  and 
deranged  digestion  (but  not  vomiting)  are  constant  symptoms, 
while  attacks  of  partial  peritonitis  and  hsemorrhages  are  not 
uncommon  towards  the  end.  In  many  cases  the  tumour 
ultimately  suppurates  in  the  centre  and  induces  symptoms  of 

'   Eeichert  unci  dn  Buis  Eeymond  :  Archiv  1866. 
E 


242  ENLARGEMENTS    OF    THE    LIVER.  lect.  vti. 

liectic  fever.  The  disease  for  w'liich  multilociilar  hydatid  would 
be  most  readily  mistaken  is  cancer,  and  like  this  it  sometimes 
runs  a  rapid  course  of  a  few  months  (see  p.  214)  ;  but  in  other 
cases  it  has  been  known  to  exist  for  ten  years  and  more  prior 
to  death.  The  treatment  recommended  for  ordinary  hydatid 
tumours  is  obviously  inapplicable  here,  and  our  efforts  must  be 
limited  to  the  relief  of  symptoms  as  they  arise.' 

XVII.    SIMPLE    CYSTS    OF    LIVER. 

Several  writers  hare  described  simple  cysts  in  the  liver, 
containing  a  clear  watery  fluid  or  thick  mucus.  They  are 
usually  very  numerous  and  of  small  size,  tbe  largest  not  exceed- 
ing- thot  of  a  hazel  nut ;  and  they  are  sometimes  associated 
with  similar  cysts  in  the  kidneys.'^  I  Trnow  no  case,  however, 
in  which  cysts  of  this  sort  have  enlarged  and  suppurated,  so  as 
to  be  distinguishable  during  life.  In  the  following  case  the 
precise  nature  of  the  disease  was  obscure.  During  life  the 
diagnosis  was  suppurating  hydatid.  It  was  clear  that  there 
was  suppuration  somewhere.  A  circumscribed  empyema  was 
negatived  by  the  history,  and  by  the  fact  that  the  fluctuation 
was  below  aiid  not  above  the  solid  liver.  Opposed  to  tropical 
abscess  was  the  fact  that  the  patient  had  never  been  out  of 
England,  nor  suffered  from  dysentery  ;  while  j^ysemic  inflamma- 
tion never  leads  to  the  large  collection  of  pus  which  was  obvi- 
ously present.  For  suppuration  outside  the  liver  no  <}ause  such 
as  disease  of  the  spine  or  ulcer  of  the  stomach  could  be  dis- 
covered. In  fact  all  causes  other  than  hydatid  appeared  to  be 
excluded ;  and  the  appearance  of  the  cysts  at  the  post-mortem 
examination  was  believed  at  first  to  confirm  the  diagnosis  made 
during  life.  But  the  failure  to  find  any  trace  of  hydatid  struc- 
ture in  the  contents  of  the  cysts  rendered  this  view  scarcely 
tenable,  for  even  in  a  sterile  hydatid  some  trace  of  the  parent 
membrane  would  have  been  present.  Fa;iling  hydatid,  we  are 
reduced  to  view  the  case  as  one  either  of  primary  abscess  or  of 
suppurating  cysts  ;  and  in  this  difficulty  it  is  much  to  be  re- 
gretted that  the  intestines  were  not  carefully  examined.  As  to 
abscess,  there  are  not  only  the  objections  already  referred  to, 

'  Tho  most  complete  account  of  imilfiloeuliii-  liyil.itid  lumoiirs  will  lio  found  in 
the  two  following  memoirs, — Do  la  Tiimeur  lly<latiqiu",  Alveolairo,  par  le  Dr.  J. 
Carriere,  Paris,  1808:  and  JOtudo  Chir.  sur  la  Tiimeiir  Ecliinocoquo  multiloculaire 
(hi  Foio.  par  lo  l)r.  Diicollier,  Paris,  1868. 

-  Frerichs,  Die.  of  Liver,  Syd.  Soc.  Kd.  ii.  223. 


LECT.  VII.  SIMPLE    CYSTS.  243 

but  the  appearance  of  the  wall  of  one  of  the  cysts  was  such  as 
could  scarcely  have  resulted  from  a  recent  inflammation,  and  it 
seems  almost  inconceivable  that  three  abscesses  should  form  in 
the  liver  in  immediate  contact  with  each  other,  the  wall  of  one 
forming  part  of  the  wall  of  the  other,  and  that  one  of  these 
should  project  as  a  cyst  from  the  surface  of  the  liver,  without 
any  sign  of  inflammation  of  the  superimposed  peritoneum. 
On  the  other  hand,  although  large  cysts  are  not  uncommon  in 
the  kidneys,  they  have  not,  so  far  as  I  know,  been  hitherto  de- 
scribed in  the  liver.  On  any  view  of  the  case,  the  symptoms 
resulting  from  the  bursting  of  one  of  the  cysts  into  the  perito- 
neum, and  particularly  the  absence  of  pyrexia,  are  interesting. 

Case  XCVIII. — Supptirating  Gijsts  in  Liver — Rupture  of  one  cyst 
into  Feritoneum.  Acute  Peritonitis — Pycemie  Abscesses  in  Liver  and 
Lungs. 

Harriet  C ,  aged  43,  adm.  into   St.   Thomas's   Hosp.    June  18, 

1875.  Father  75,  mother  76,  both  alive  and  healthy ;  a  sister  of  mother 
died  of  phthisis ;  three  brothers  and  five  sisters,  all  alive,  34  to  55, 
and  well,  except  one  brother  who  has  delicate  lungs.  Married ;  five 
children ;  two  died  in  infancy.  When  quite  a  child,  patient  had  a 
severe  attack  of  inflammation  of  lungs,  and  ever  since  had  been  delicate 
and  apt  to  catch  cold.  At  age  of  30  had  a  scaly  eruption  over  body, 
which  disappeared  after  eight  weeks.  Had  never  been  out  of  England. 
Present  illness  commenced  about  20th  April  with  loss  of  appetite  and 
strength,  emaciation,  sleeplessness,  thirst,  and  occasional  sickness. 
After  a  fortnight  first  felt  pain  in  region  of  liver  and  right  shoulder, 
not  constant  or  severe  except  when  she  lay  on  right  side  or  moved 
about.  Four  weeks  before  admission  she  became  much  worse  ;  intense 
thirst,  skin  hot  and  dry  in  daytime,  profuse  sweating  at  night,  and 
rapid  emaciation. 

On  admission,  ver}^  prostrate  and  emaciated  ;  hectic  flush  on  cheeks  ; 
profuse  perspiration  at  night,  or  whenever  she  sleeps.  Temp.  102°  to 
104°.  Pulse  108.  Heart's  sounds  healthy.  Tongue  too  red,  and 
dryish;  no  appetite  ;  thirst;  bowels  open.  Still  much  pain  in  right 
side,  increased  greatly  by  slightest  movement.  In  right  side  of  abdo- 
inen  is  a  prominent  swelling,  reaching  down  to  an  inch  below  umbili- 
cus and  forming  a  distinct  prominence  between  that  and  rio-fit  ribs, 
which  do  not  bulge  ;  dull  on  percussion,  the  dulness  continuous  with 
that  of  liver,  which  reaches  to  ^  in.  below  right  nipple  ;  total  dulness 
in  r.  m.  1.  10  in.  Surface  of  swelling  smooth,  tender,  soft  and  elastic, 
with  a  thrill  as  if  from  fluid.  JSTo  evidence  of  fluid  in  peritoneum  ;  no 
enlargement  of  abdominal  veins  ;  no  jaundice ;  no  oedema  of  leo"=. 
Posteriori}',  hepatic  dulness  extends  about  two  inches  above  normal 
level.     Urine  contains  neither  albumen  nor  bile.     Sleeps  badly. 

K  2 


244  ENLARGEMENTS    OF    THE    LIVER.  i.ect.  tii. 

Patient  was  ordei-ed  quinine,  mineral  acids  and  four  oz.  of  brandy. 
On  Jnne  19  an  exploratoiy  pnnctnre  was  made  below  right  ribs  with 
fine  trocar;  a  few  small  beads  of  thick  yellow  pus  oozed  out.  A  few 
hours  later  a  large  trocar  was  introduced  at  same  spot ;  only  about  a 
drachm  of  thick  yellow  pus  came  out.  The  silver  cannula  was  fastened 
in  and  the  opening  covered  with  oakum.  The  opening  gave  great  relief, 
but  on  21st  she  had  a.  rigor  lasting  twelve  minutes,  followed  by  a  feeling 
of  sinking  and  by  friction  and  moist  sounds  over  front  of  right  lung. 
Elastic  tubing  was  substituted  for  silver  cannula.  Thick  pus  continued 
to  ooze  slowly  from  tube,  which  at  no  time  contained  any  trace  of 
echinococci.  On  23rd,  upper  margin  of  hepatic  dulness  had  receded 
to  fully  an  inch  below  nipple.  A  second  slight  rigor.  On  24th, 
tympanitic  distension  of  abdomen,  but  no  tenderness.  Frequent  retch- 
ing. Temp.  99.  Pulse  128.  Increased  prostration.  Notwithstanding 
opiates,  these  symptoms  persisted  with  occasional  hiccough.  On  June 
28  had  a  sensation  of  profound  sinking  and  thought  she  was  dying, 
but  rallied.  On  June  30  it  Avas  noted  that  upper  margin  of  hepatic 
dulness  had  receded  to  1^  in.  below  nipple,  while  lower  margin  of 
tumour  had  ascended,  so  that  total  dulness  in  r.  m.  1,  was  only  7^  in. 
On  July  3  this  was  reduced  to  6^  in. ;  no  sign  of  fluid  could  be  dis- 
covered in  tumour,  but  there  was  clear  evidence  of  fluid  in  peritoneum. 
Abdomen  not  tender  and  temperature  normal.  After  this  became  daily 
weaker,  was  occasionally  delirious,  and  aphtha3  appeared  on  tongue, 
and  feet  more  oedematous.  On  July  9  had  a  slight  convulsive  seizure, 
and  on  12th  she  died.  After  June  24  temperature  w^as  never  elevated 
and  was  often  subnormal,  once  as  low  as  9G°. 

Antojjsij. — Intestines  greatly  distended  with  gas.  Transverse  colon 
adherent  along  its  anterior  border  to  abdominal  wall  by  somewhat  firm 
adhesions,  so  as  to  form  a  sort  of  septum  dividing  peritoneal  cavity  into 
an  upper  and  lower  portion.  LoM^er  poi'tion  contained  about  7  pints 
of  turbid  serous  fluid,  mixed  with  a  large  quantity  of  thick  yellow 
curdy  pus,  which  coated  and  was  adherent  to  coils  of  small  intestine. 
The  fluid  had  not  appearanc3  of  ordinary  peritoneal  exudation,  but 
looked  like  a  mixture  of  thick  pus  with  it.  Anterior  surface  of  liver 
connected  by  soft  adhesions  to  abdominal  wall  ;  corresponding  to 
external  opening  adhesions  were  firm  and  fibrous,  and  sinus  passed 
through  them  directly  backwards  into  liver.  Lower  border  of  liver 
rather  firmly  adherent  to  colon,  which  slightly  overlapped  it,  its  edge 
not  reaching  much  below  normal  level.  Between  adhesions  which  united 
hepatic  flexure  of  colon  with  abdominal  wall  and  under  surface  of 
liver  was  an  irregular  cavity  of  some  size,  full  of  thick  curdy  pus,  and 
communicating  with  lower  portion  of  peritoneal  cavity  by  an  oblique 
sinus  passing  down  through  layers  of  adhesion.  Several  circumscribed 
abscesses,  about  size  of  a  marble,  were  seen  on  surface  of  liver,  but  no 
cyst  was  visible  before  removal  of  organ.  On  removal,  greater  part  of 
right  lobe  was  found  to  be  elastic  and  fluctuating,  and  upj)er  surface 


LKCT.  vir.  TUBERCLE.  245 

was    convex,  pushing-    diaphragm   considerably   upwards.     On   under 
surface  of  right  lobe,  near  anterior  margin,  was  a  collapsed  cyst,  about 
size  of  an  oi'ange,  with  a  smooth  thick  fibrous  wall,  which  communi- 
cated by  two  small  apertures  in  its  under  surface  with  abscess-cavity 
above  referred  to  formed  by  adhesions  on  under  surface  of  liver.     It 
Avas  this  abscess-cavity  which  had  apparently  been  opened  during  life. 
Further  back  in  liver   and    closely  adjacent    to    collapsed   cyst    was 
another,  of  about  same   size   and  projecting  from  surface ;  and  above 
this  was  another  larger  cyst,  forming  projection  on  upper  surface  of 
right  lobe,  biit  covered  by  a  thin  layer  of  hepatic  tissue.     Both  these 
cysts  contained  a  thick   curdy  puriform  fluid,  their  inner  surface  was 
irregular  and  ragged,  and  larger  one  opened  into  a  sort  of  cavernous 
structure,  formed  apparently  by  multiple  abscesses   in    substance    of 
liver.     In  none  of  cysts  could  any  trace  of  hydatid  membrane,  echino- 
cocci,  or  booklets  be  discovered  by  naked  eye  or  on  most  careful  micro- 
scopic examination  ;  gall-bladder  contained  normal  fluid  bile.     Spleen 
6   oz.,  firm  and  dark.     Kidneys  rather  small,   but  structure  normal. 
Intestines  not  carefully  examined.     Heart  small  but  healthy.     Right 
pleura   contained   14   oz.   of  slightly  turbid  serum  ;  surface   of  right 
lang  rough  from  recent  lymph,  and  several  small  pygemic  infarcti  in 
middle  and  lower  lobes.     Two  or  three  similar  infarcti  in  lower  lobe  of 
left  lung. 

XVIII.    TUBERCLE    OP    THE    LIVER. 

Enlargement  of  tlie  liver  is  sometimes  due  to  the  deposit  of 
tubercle.  The  subject  of  tubercle  of  the  liver  has  still  to  be 
investigated.  Rokitansky  speaks  of  hepatic  tubercle  occurring 
'  in  the  shape  of  semi-transparent,  greyish,  crude,  miliary  granu- 
lations, in  which  case  it  is  more  especially  the  product  of  acute 
tuberculosis.'  ^  Frerichs  also  mentions  the  occurrence  of  no- 
dules of  yellow  tabercle  in  the  liver,  which  may  soften  into 
vomicse ;  while  other  observers  have  noted  contractions  and 
dilatations  of  the  fine  bile-ducts  from  the  deposit  of  tubercle 
in  their  walls.-  Enlargement  of  the  liver  occurring  in  the 
course  of  general  tuberculosis  may  be  due  to  tubercle,  as  well 
as  to  fatty  or  waxy  dei30sit.  Thei'e  are  no  symptoms  by  which 
the  tubercular  enlargement  can  be  distinguished  during  life, 
and  its  discovery  would  not  materially  modify  either  the  pro- 
gnosis or  the  treatment.  In  the  following  case  the  liver  was  in- 
filtrated with  minute  miliary  tubercles  ;  the  jaundice  was  appa- 
rently due  to  concurrent  catarrh  of  the  biliary  passages,  which 
was  subsiding  before  the  patient's  death. 

'  Path.  Anat..  Syd.  Soc.  Traiisl.  vol.  ii.  p.  149. 
2  Prericlis,  Dis,  of  Liver,  Syi.  Soc.  Ed.  ii.  22 


246  ENLARGEMENTS    OF    THE    LIVER.  I-kct.  vii. 

Case  XCIX. — General  Tulerculosis — EnJarr/cmeiit  of  Liver  from  Tuher- 
cidar  Deposit — Jaundice  from  Catarrh  of  llile-ducts — Embolism  of 
iSpleen. 

Mary  C ,  aged  40,  adm.  into  Middlesex  Hosp.  under  my  care, 

Dec.  17,  1867.  Father  and  mother  had  both  died  at  age  of  50,  of 
some  chest  affection,  and  of  eleven  brothers  and  sisters  all  were  dead 
but  one,  though  patient  could  not  say  of  what  they  had  died.  Patient 
was  extremely  prostrate,  and  somewhat  confused  in  her  mind.  So  far 
as  her  history  could  be  obtained,  it  was  to  the  effect  that  six  months 
before  she  had  lost  her  appetite,  and  had  vomited  about  half  an  hour 
after  every  meal.  Two  or  three  months  after  this  she  became  jaundiced. 
She  had  not  suffered  from  cough,  hiemoptysis,  rigors,  or  night-sweats, 
but  from  first  she  had  lost  flesh  and  strength. 

On  admission,  jaundice  of  moderate  intensity  of  skin  and  con- 
junctivte  ;  urine  exhibited  reaction  of  bile-pigment ;  copious  deposit  of 
lithates  ;  no  albumen.  No  itchiness  of  skin  ;  tongue  dry  and  brown, 
except  at  edges,  Avhich  were  preternaturally  red.  Patient  stated  that 
up  to  time  of  admission  she  had  vomited  almost  everything  within  half 
an  hour  of  swallowing  it,  but  she  did  not  vomit  once  after  admission. 
A  motion  passed  soon  after  admission  Avas  formed,  and  of  a  dark 
brown  bilious  colour.  Hepatic  dnlness  increased,  in  right  mammary 
Hue  measuring  5  inches,  and  extending  fully  an  inch  below  margin  of 
ribs  ;  portion  below  ribs  smooth  and  slightly  tender.  Pulse  120,  small 
and  feeble ;  a  faint  systolic  bellows  murmur  at  left  apex  of  heart  ; 
temperature  100°'2.  Nothing  to  attract  attention  to  lungs,  which  in 
patient's  weak  state  were  not  examined.  A  large  superficial  bed-sore 
over  sacrum. 

Patient  was  treated  with  bismuth,  chloric  ether,  and  stimulants, 
but  she  became  rapidly  more  prostrate ;  low  muttering  delirium  set  in, 
motions  and  urine  were  passed  in  bed,  and  death  took  place  on 
Dec.  28. 

Autopsii. — A  pint  of  clear  serum  in  peritoneum.  Liver  very  large  ; 
weighed  77  oz.  ;  capsule  not  thickened  or  adherent ;  surface  generally 
smooth,  but  marked  by  numerous  minute  depressions  and  elevations  ; 
glandular  tissue  pale  ye' low  and  opaque,  exactly  like  that  of  a  fatty 
liver,  from  which  it  differed,  however,  in  being  remai'kably  firm  and 
tough.  On  section,  a  little  thin  watery  bile  could  be  squeezed  from 
the  divided  bile-ducts,  many  of  which  presented  small  dilatations.  Gall- 
l)ladder  contained  a  small  quantity  of  a  similar  fluid,  as  well  as 
numerous  minute,  black,  gritty  concretions.  On  microscopic  examina- 
tion, it  was  ascertained  by  Dr.  Cayley  that  enlargement  of  liver  was 
due  to  presence  of  Tiumerous  miliary  tubercles  scattered  through  glan- 
dular tissue  between  lobules,  and  presenting  all  structural  characters 
of  grey  tubercle,  some  of  which  were  just  visil)le  to  naked  eye  as 
minute  grey  specks.     Mucous  membrane  of  stomach  pale,  but  imme- 


LECT.  Til.  LYMPHATIC    GROWTHS.  24/ 

diately  below  jDylorus  tliat  of  duodenum,  for  about  8  inches,  intensely 
injected,  tumid,  and  studded  with  numerous  small  granular  punctated 
elevations,  ajDparently  enlarged  solitary  glands.  Lining  membrane  of 
common  bile-duct  also  very  red,  and  mucous  membrane  slightly 
swollen,  but  passage  not  obstructed.  Three  small  tubercular  ulcers  in 
lower  part  of  ileum.  Both  lungs  g-tudded  with  numerous  grey  miliary 
tubercles,  and  near  both  apices,  a  small  patch  of  old  g^i'ey  tubercle. 
Edge  of  one  of  flaps  of  mitral  valve  much  thickened.  No  lymph  at 
base  of  brain,  and  no  tubercles  in  pia^mater,  but  much  serous  fluid 
beneath  arachnoid  and  in  cerebral  ventricles ;  in  cavity  of  arachnoid 
over  both  hemispheres  was  a  thin  film  of  extravasated  blood.  In 
uterus  a  fibrous  tumour  as  large  as  a  cocoa-nut,  and  position  of  right 
ovary  was  occupied  by  a  tumour  as  large  as  an  orange,  partly  solid, 
and  partly  breaking  down  into  a  soft  cheesy  material.  Right  Fallopian 
tube  as  large  as  a  finger,  and  filled  with  soft  putty-like  material ;  its 
lining  membrane  rough  and  u'lcerated,  like  that  of  pelvis  of  kidney  in 
tubercular  pyelitis.  Spleen  large ;  weighed  15^  oz.  ;  very  soft,  and 
studded  with  numerous  abscesses,  from  a  pea  to  a  hazeli-nut  in  size,  and 
containing  thick  yellow  pus  ;  also  several  solid  deposits  in  spleen,  having 
the  characters  of  recent  infarcti.  Cortices  of  both  kidneys  studded 
with  minute  yellow  tubercular  granules. 


XIX.    ENLARGEMENT    OF    LIVER    FROM    LYMPHATIC    GROWTHS. 

In  leuksemia,  and  in  cases  where  there  is  a  general  tendency 
to  enlargement  of  the  lymphatic  system  independent  of  lenkse- 
mia,  the  liver  may  be  found  studded  with  new  formations,  some- 
times minute  and  grejish- white,  not  unlike  miliary  tubercles,  at 
other  times  opaque  yellow  and  as  large  as  a  cherry.  Structur- 
ally these  formations  resemble  lymphatic  tissue,  and  they  are 
believed  to  be  developed  in  connection  with  the  lymphatic  sys- 
tem. When  very  numerous  they  may  produce  enlargement  of 
the  liver.  In  any  case^  therefore,  of  leuksemia,  or  of  general 
enlargement  of  the  lymphatic  glands,  enlargement  of  the  liver 
may  be  due  to  this  cause  or  to  simple  hypertrophy  (see  p.  54)  ; 
but  it  will  call  for  no  special  treatment  apart  from  that  of  the 
p-eneral  condition.^ 


XX.    ENLARGEMENT    OF    THE    LIVER    WITH    XANTHELASMA. 

The  following  case  was  a  well-marked  example  of  the  disease 
first  described  by  Dr.  Addison  and  Sir  W.  Gull  in  the  seventh 

^  For  ilhistrations  of  this  disease  in  the  Liver,  I  must  refer  to  Cases  reported  by 
mc  in  the  Pathological  Transaction&.     Vol.  xx.  pp.  192,  198  ;  and  vol.  xxi.  p.  372. 


248  ENLARGEMENTS    OF    THE    LIVEK.  i.ECr.  vn. 

volume  of  the  second  series  of  the  '  Guj's  Hospital  Reports,' 
under  the  name  of  '  vitiligoidea,'  and  which  Mr.  Erasmus 
Wilson  subsequently  designated  '  xanthelasma.'  In  the  nine- 
teenth volume  of  the  '  Pathological  Transactions  '  two  cases 
were  recoi'ded  by  Dr.  C.  Hilton  Fagge,  who  in  a  summary  of 
our  then  existing  knowledge  of  the  subject  made  the  following 
statement.  '  The  nature  of  the  change  in  the  liver  in  this 
affection  is  as  yet  entirely  unknown.  So  far.as  I  can  ascertain, 
a  post-mortem  examination  has  as  yet  been  made  in  no  case  of 
vitiligoidea.  The  liver  seems  to  be  greatly  and  uniformly  en- 
larged. No  tubera  or  nodules  have  been  felt  on  its  surface ' 
(p.  448). 

Patches  of  vitiligoidea  plana,    such  as  existed  in  Angelo 

S ,  are  occasionally  met  with  in  the  eyelids,  independently 

of  jaundice  or  of  an}-  obvious  disease  in  the  liver,  or  may,  as 
Dr.  Church  '  has  pointed  out,  be  sometimes  hereditary,  but  this 
does  not  detract  from  the  interest  of  the  fact  that  in  many  in- 
stances the  morbid  change  in  the  skin  is  associated  with  jaun- 
dice and  enlargement  of  the  liver,  presenting  peculiar  clinical 
characters.  The  jaundice,  as  Dr.  Fagge  remarks,  is  usually  of 
no  ordinary  kind.  It  is  peculiar  in  being  very  chronic  and  per- 
sistent, lasting  for  months  or  even  years,  and  although  very 
decided  in  its  hue,  in  being  in  most  cases  (but  not  invariably) 
independent  of  complete  obstruction  of  the  hepatic  duct,  bile 
being  usually  found  in  sufficient  quantity  in  the  alvine  evacua- 
tions. The  enlargement  is  distinguished  by  being  great  and 
uniform,  and  by  its  surface  being  firm,  smooth,  and  somewhat 
tender. 

In  the  following  case  the  enlargement  was  found  to  be  due 
to  an  excessive  formation  of  fibroid  tissue,  and  the  case  ap- 
peared to  be  an  example  of  interstitial  hej^atitis,  such  as  I  have 
referred  to  in  a  former  lecture  (p.  189).  Everywhere  along  the 
portal  canals  and  between  the  lobules  the  liver  was  pervaded 
by  a  dense,  firm  deposit,  made  up  of  fibrous  tissue  and  masses 
of  minute  corpuscles  or  nuclei.  The  glandular  tissue  of  the 
liver  was  cut  up  by  this  dense  deposit  into  circumscribed  patches 
or  islands,  just  as  we  see  in  a  cirrhotic  liver.  The  view  that 
the  case  was  one  of  enlarged  cirrhotic  liver  is  confirmed  by  the 
man's  having  been  addicted  to  drinking  spirits  in  great  excess. 
But,  on  the  other  hand,  the  jaundice  was  greater  and  more 
persistent  than  is  usual  in  cirrhosis,  and  there  is  no  mention  of 
'  Barth.  IIosp.  Rep.  vol.  x. 


LECT.  Yii,  ENLARGEMENT    WITH    XANTHELASMA.  249 

intemperance  in  most  of  the  recorded  cases  of  enlargement  of 
the  liver  accompanying-  vitiligoidea. 

The  cause  of  the  jaundice  was  not  very  apparent.  The 
bilious  motions  seemed  to  show  that  it  was  independent  of  any 
obstruction  of  the  large  bile-ducts,  while  its  duration  and  the 
absence  of  any  symptoms  of  blood-poisoning  until  shortly  before 
death  were  opposed  to  the  view  that  it  was  due  to  a  morbid 
state  of  the  blood.  The  vitiligoidea  itself,  however,  indicated  a 
very  disordered  state  of  the  patient's  nutrition,  so  tliat  the 
jaundice  may  possibly  have  been  due  to  the  bile-pigment,  which 
is  being  constantly  reabsorbed,  not  being  sufiiciently  transformed 
into  urinary  pigment  and  other  materials,  by  which  in  health 
it  is  eliminated  from  the  body ;  or  possibly  it  may  have  been 
occasioned  by  partial  occlusion  of  the  bile-duct  from  the  pres- 
sure of  enlarged  glands  in  the  fissure  of  the  liver. 

Case  C.  was  the  first  in  which  the  condition  of  the  enlarged 
liver  so  commonly  associated  with  xanthelasma  was  carefully 
examined  after  death.^  Similar  appearances  were  subsequently 
found  in  another  case  by  Dr.  Hilton  Fagge.^  But  it  has  been 
now  conclusively  proved  that  very  different  affections  of  the 
liver  may  lead  to  the  development  of  xanthelasma.  In  a  sub- 
sequent lecture  I  shall  relate  to  you  a  case  in  which  it  resulted 
from  protracted  obstruction  of  the  bile-duct  by  a  gall-stone. 
A  similar  case  has  been  reported  by  Dr.  Pye  Smith  ;^  while 
Drs.  Wickham  Legg  and  Duckworth  have  observed  it  in  jaun- 
dice caused  by  obstruction  of  the  hepatic  duct  by  a  hydatid,* 
and  Dr.  Moxon  has  seen  it  follow  obstruction  of  the  duct  by 
simple  stricture."''  It  would  appear  that  this  peculiar  condition 
of  the  skin  is  apt  to  be  developed  in  any  case  of  jaundice,  if 
sufficiently  protracted. 

Case  C. — Enlargement  of  Liver  from- Interstitial  Hepatitis — Jaundice — 

Xanthelasma. 

Angelo    S ,  aged  41,  a  paper-dealer-,  admitted  into  Middlesex 

Hospital,  July  14tlL,  1868.  Father  and  mother  both  dead  ;  he  could 
give  no  information  respecting  cause  of  their  death.  For  many  years 
he  had  been  very  intempei-ate,  drinking  large  quantities  of  rum,  brandy, 
and  gin  ;  and  for  four  or  five  years  lie  had  suffered  a  good  deal  from 

'  The  Case  was  reported  in  Path.  Trans.  1869,  vol.  xx.  p,  187. 
■  lb.  1873,  vol.  xxiv.  p.  242. 

*  lb.  vol.  xsiv.  p.  250. 

■*  lb.  vol.  XXV.,  p.  3  55  and  St,  Bartholomew's  Hosp.  Eep.  vol.  x.  p.  60. 

*  lb.  vol.  xxiv.  p.  129. 


250  ENLARGEMENTS    OP    THE    LIVER.  lect.  th. 

indigestion  and  occasional  vomiting,  especially  in  morning.  Two  years 
before  admission  vomiting  had  become  more  constant,  and  always 
occurred  directly  after  taking  food.  About  same  time  patient  bad 
become  weak  and  languid  ;  he  had  lost  appetite,  and  had  noticed  ab- 
domen to  swell.  Six  months  later  jaundice  set  in,  and  had  never  since 
disappeared.  Twelve  months  before  admission  he  had  begun  to  suffer 
pain  in  region  of  liver  and  between  shoulders,  and  six  months  before 
admission  he  had  first  noticed  pale  discoloured  patches  on  eyelids. 
During  last  few  months  he  had  had  occasional  epistaxis,  and  now  and 
then  had  passed  a  little  red  blood  per  anum,  although  he  was  not  aware 
that  he  had  piles.  Motions  had  always  presented  a  bilious  yellow 
character. 

On  admission  weak   and   emaeiatcd,    and    obliged    to    keep   bed. 
Whole  surface  of  body  and   conjunctivas  deeply  jaundiced.     On  both 
eyelids  of  both  eyes  were  light  cream-coloured  patches,  contrasting 
strongly  with  surrounding  dark  jaundiced  tint.     Lower  eyelid  of  right 
eye  almost  completely  involved  in  tliis  discolouration,  and  in  other  lids 
patches  varied  from  size  of  a  pin's  head  to  about  half  an  inch  in  dia- 
meter.    Patches  had  a  smooth  satiny  feel ;  edges  were  well  defined, 
and  they  appeared  slightly  raised  above  surrounding  surface,  but  were 
really  not  so.     No  white  patches  on  the  gums,  and  no  tubercular  pro- 
minences- an  hands  or  elsewhere.     Front  of  chest  and   neck  were  also 
variegated  by  large  patches  of  brownish  discolouration,    running  into 
one  another,  darker  than  surrounding  jaundiced   skin,   and  scaly  on 
surface,  like  pityriasis.     Circumscribed  circular  patches  of  a  similar 
nature,  about  size  of  a  sixpence,  on  both  forearms  near  wrists.     These 
brown  patches-  were  seat  of  considerable  itchiness,  from  which  skin 
generally  was  free.     Abdomen  greatly  distended,  owing  mainly  to  en- 
largemenifc  of  liver ;  girth  at  umbilicus  33^  in.  ;  at  lower  margin  of  ribs 
it  was  35-^  in.     Vertical  hepatic   dulness   measured    G  in.   in   anterior 
mesia>l  line^  9  in.  in  right  mammary  line,  and  10  in.  in  axillary  line, 
where' it  reached  down  to  crest  of  ilium.     Liver   was- seat  of  constant 
pain,  and  portion  vrhich  projected  beyond  ribs  was  smooth,  dense,  and 
slightly  tender  ;  lower-margin  sharp  and'hard.     Spleen  much  enlarged  ; 
its  lower  margin  distinctly  felt  projecting  three  inches   beyond  margin 
of  left  ribs.     No   ascites,  and  no  enlargement  of  superficial,  abdominal 
veins.     Tongue  moist,,  and  ceaited  with  a  white  fur.     Still  occasional 
vomiting  of  food.     Bowels  regular  ;  motions  formed,  and  well  coloui-ed 
with  bile-pigment.     Urine  contained  much  bile-pigment  and  a  trace  of 
albumen,    but   no    sugar,    leucin,   or  tyrosin ;    specific    gravity    1012. 
Pulse  84  ;  cardiac  dulness  slightly  increased  ;  a  systolic  bellows-mur- 
mur heard  distinctly  over  third  left  costal  cartilage.     Slight  dulness, 
with  feeble  breathing,  over  lower  and  back  part  of  right  Inng. 

After  admi.ssion  vomiting  became  worse,  but  was  relieved  for  a 
time  by  pills  containing  creasote  and  morphia.  It  continued,  however, 
to  recur  until  death,  and  on  August  23rd  and  21th  patient  vomited  a 


T.ECT.  VII.  ENLARGEMENT    "WITH    XANTHELASMA..  25 1 

considerable'  quantity  of  sanguineous  liquid.  He  had  also  repeated 
attacks,  of  diairrlioea,  motions  always  containing  bile,  and  occasionally 
a  little  red  Hood.  Tongue  was  usually  dry  and  brown.  Liver  was 
always  seat  of  much  pain,  and  very  tender,  but  no  material  change  took 
place  in  its  size  while  under  observation,  although  as  patient  lost  flesh 
enlargement  of  liver  became  more  a,pparent ;  its  margin  could  be 
distinctly  seen  through  abdominal  parietes  moving  np  and  down  with 
respiration.  Jaundice  became  darker  and  assumed  somewhat  of  a 
bronzed  hue,  but  conjunctiva?  became  less  yellow,  and  there  was  no 
increase  or  alteration  of  light-coloured  patches  on  the-  eyelids.  Urine 
was  examined  on  several  occasions  for  leucin  and  tyrosin,  but  neither 
was  found  ;  usually,  but  not  always,  it  contained  a  trace  of  albumen. 
Patient  continued  to  lose  flesh,  and  became  greatly  exhausted.  About 
end  of  August  he  began  to  suffer  from  hicco^Jgh,  restlessness,  and 
delirium.  When  thwarted  in  the  least  he  kept  shouting  at  top  of  his 
voice,  so  that  it  was  necessary  to  remove  him  to  the  d;elirious  ward. 
On  Sept.  4th  aphthse  were  noticed  on  tongue  and  on  roof  of  mouth  ; 
diarrhoea  recurred,  and  motions  were  passed  in  bed.  O.i  Sept.  19th 
teeth  and  tongue  became  coated  with  sordes,  and  on  Sept.  20th  the 
man  died. 

Autopsij. — Sections  were  made  with  a  Valentin's  knife  through 
cream-coloured  patches  in  eyelids  in  situ.  The  colour  was  found  to  be 
due  to  deposit  in  meshes  of  cutis  of  a  large  quantity  of  oily  grannies, 
both  isolated  and  aggregated  in  masses,  and  always  most  abundant  in 
neighbourhood  of  hair-follicles,  which  in  other  respects,  however,  ap- 
peared normal.  When  stained  with  carmine  a  distinct  nucleus  could 
be  seen  in  centre  of  the  oily  masses.  The  epidermal  cells  were  not 
affected.  The  oily  matter  was  in  such  quantity  in  cutis  that  it  poured 
out  like  a  milky  fluid  from  a  section  placed  in  water, 

A  few  ounces  of  fluid  in  peritoneum.  Liver  very  large,  its  lower 
margin  reaching  to  below  umbilicus  ;  it  weighed  80|  oz.  ;  outer  sur- 
face smooth,  capsule  thickened,  and  at  many  places  attached  to  sur- 
rounding parts  by  firm  old  adhesions ;  structure  firm,  and  on  section 
presented  a  smooth  dense  surface  of  a  pale  greyish  colour,  with  ver}'- 
little  appearance  of  ordinary  secreting  tissue,  but  apparently  a  great 
increase  of  fibrous  element.  Here  and  there  were  darker  islands  of  a 
jaundiced  tint,  which  seemed  to  be  remains  of  secreting  tissue.  On 
microscopic  examination  denser  material,  of  which  gi^eater  portion  of 
liver  was  composed,  was  found  to  consist  of  nuclear  and  fibroid  tissue 
in  portal  canals  and  between  lobules  ;  nuclear  element  was  particularly 
abundant ;  groups  of  rounded  nuclei,  or  bodies  resembling  tymphatic 
corpuscles,  were  aggregated  round  minute  vessels  between  lobules.  In 
some  parts  of  dense  structure  the  nuclear,  and  in  others  the  white 
fibrous  tissue,  predominated.  At  some  places  nuclei  seemed  club- 
shaped  or  oat-shaped,  and  appeared  to  pass  into  fibres  ;  this  appearance, 
however,  was  quite  exceptional.     Yellow  portions  of  liver  were  found 


252  ENLARGEMENTS    OF    THE    LIVER.  i.ect.  vii. 

to  be  made  up  of  hepatic  lobules,  cells  of  which  were  loaded  with  oil 
and  bile-pigment.  Green  bile  was  found  in  duodenum,  and  bile  could 
be  squeezed  with  ease  from  gall-bladder  along  bile-duct  into  bowel. 
Glands  in  fissure  of  the  liver  along  spine,  and  along  course  of  iliac 
arteries,  were  much  enlarged  and  jaundiced.  Spleen  greatly  enlarged  ; 
weighed  23  oz. ;  capsule  much  thickened,  and  in  its  interior  numerous 
opaque  yellow  embolic  deposits  up  to  size  of  a  large  pea.  On  posterior 
wall  of  stomach,  a  fevv  inches  from  pylorus,  was  a  simple  ulcer,  size  of 
a  crown-piece,  base  of  which  was  formed  by  tissue  of  pancreas  ;  its  sur- 
face had  a  glazed  cicatrized  appearance,  and  there  was  slight  pucker- 
ing of  edges.  Both  kidneys  large  ;  they  weighed  together  lOJ  oz. ; 
right  contained  numerous  opaque  yellow  embolic  deposits,  one  of  them 
as  large  as  a  walnut ;  left  kidney  contained  two  or  three  similar  but 
smaller  deposits.  Heart  was  not  hypertrophied  ;  it  weighed  II5  oz. ; 
aortic  valves  competent,  but  two  of  them  grown  together,  and  their 
point  of  attachment  to  aorta  partially  separated,  so  that  they  seemed 
to  form  one  valve  ;  several  small  rough  vegetations  on  their  ventricu- 
lar surface. 

XXI.    ENLARGEMENTS  OF    THE    GALL-BLADDER. 

The  gall-bladder  maj  be  enlarged  from  various  causes,  so 
as  to  form  a  tumour  attached  to  the  liver,  and  appreciable 
through  the  abdominal  parietes.  The  causes,  the  sjnnptoms, 
and  the  ti'eatment  of  these  enlargements  will  be  considered  in 
a  future  lecture.     (Lecture  XIII.) 


253 


LECTURE   VIII. 
CONTRACTIONS  OF  THE  LIVER. 

SIMPLE     ATROPHY ACUTE     OR      TELLQ-W     ATROPHY CHRONIC      ATROPHY (ciRRHOSlS 

SIMPLE   AXD    SYPHILITIC    INDURATION — RED    ATROPHY). 

Gentlemen, — In  previous  lectures  I  have  described  to  jou  the 
normal  limits  of  the  area  of  hepatic  dulness  (p.  2),  as  well  as 
the  principal  causes  of  apparent  and  real  enlargement  of  the 
liver,  with  the  means  of  recognising-  them.  "We  have  now  to 
consider  the  chief  causes  of  a  diminution  in  the  area  of  hepatic 
dulness,  and  their  distinctive  characters.  And  in  the  first 
place  you  must  remember  that  the  area  of  hepatic  dulness 
often  appears  diminished,  although  the  organ  in  reality  retains 
its  normal  weight  and  bulk. 

SPURIOUS    CONTRACTIOISrS    OP    THE    LIVER. 

The  main  conditions  likely  to  indu.ce  an  apparent  diminution 
in  the  size  of  the  liver  are  as  follows  : 

1 .  Tympanitic  distension  of  the  bowels,  and  particularly  of 
the  transverse  colon  and  stomach,  may  prevent  the  lower 
margin  of  the  liver  being  felt,  and  diminish  the  area  of  hepatic 
dulness  in  several  ways  : 

a.  A  portion  of  stomach  or  intestine  distended  with  gas 
may  become  interposed  between  the  surface  of  the  liver  and  the 
abdominal  parietes. 

h.  When  the  lower  margin  of  the  liver  is  thin,  and  when 
there  is  excessive  tympanitic  distension  of  the  subjacent  boAvels 
pushing  the  liver  forwards  and  rendering  the  abdominal 
parietes  tense,  the  lower  edge  of  the  liver  may  escape  detection 
on  palpation,  and  its  dulness  on  percussion  may  be  imper- 
ceptible. 

c.  In  excessive  tympanites  the  antero-posterior  diameter 
of  the  abdominal  cavity  is  increased,  and  the  lower  portion  of 


254  OONTK ACTIONS    OF    THE    LIVER.  lv.ct.  tiii. 

the  liver  may  be  elevated  so  tliat  a  smaller  portion  of  it  than  is 
natural  is  in  contact  with  the  abdominal  parietes. 

In  one  or  more  of  these  ways  the  normal  hepatic  dulness 
may  be  diminished  or  may  even  entirely  disappear,  so  that  the 
pulmonary  sound  is  immediately  succeeded  by  that  of  the  bowel. 
The  liver  may  thus  appear  greatly  diminished,  although  its 
size  is  not  in  reality  altered.  You  will  find  a  remarkable  case 
of  this  sort  recorded  by  Dr.  Bright,  where,  on  opening  the 
body,  neither  the  liver  nor  the  colon  presented  itself  to  view, 
but,  in  their  stead,  the  convolutions  of  the  small  intestines, 
which  were  found  to  have  come  completely  in  front  of  the  liver, 
the  colon  and  the  omentum  doubling  over  the  liver  and  press- 
ing it  back,  and  having  made  deep  furrows  on  its  anterior 
surface.'  The  fact  of  hepatic  contraction  being  of  this  spurious 
character  ought  always  to  be  suspected  under  the  folloAviug 
circumstances  : — 

a.  The  very  fact  of  there  being  tympanitic  distension  of  the 
bowels  ought  to  suggest  caution  in  inferring  the  existence  of 
real  atrophy  of  the  liver  from  a  diminished  area  of  hepatic 
dulness.  The  same  caution  is  necessary  in  cases  of  ascites. 
The  fluid  in  the  peritoneum  pushes  up  the  bowels  which  may 
be  only  moderately  distended  with  gas,  but  which  may  thus 
come  to  produce  the  same  result  as  more  extensive  tympanites ; 
and  this  fallacy  is  of  the  greater  importance  inasmuch  as: 
ascites  is  a  common  consequence  of  real  atrophy  of  the  liver. 

h.  Variation  in  the  extent  of  hepatic  dulness  at  different 
times  is  a  character  of  spurious  atrophy  of  the  liver  most  useful 
in  diagnosis.  The  dulness  of  the  liver  will  vary  in  its  extent 
according  to  the  amount  of  gas  in  the  stomach  and  bowels,  or 
of  fluid  in  the  peritoneum.  The  diagnosis  will  therefore  be 
facilitated  by  oft-repeated  examinations,  and  particularly  by 
examinations  made  before  meals,  and  after  the  bowels  have 
been  cleared  out  by  a  purgative. 

c.  Variation  in  the  extent  of  hepatic  dulness  at  different 
places  is  not  uncommon  in  cases  of  spurious  atroph}'.  Tym- 
])anitic  distension  of  the  stomach  and  bowels  may  diminish  or 
obliterate  the  hepatic  dulness  in  the  mesial  and  right  mammary 
lines,  but  is  not  likely  to  affect  it  materially  in  the  axilhiry  or 
dorsal  lines.  Occasional!}',  too,  the  space  where  the  hepatic 
dulness  is  obscured  may  be  even  more  circumscribed,  as  when  a 

'  Abdom.  Tumo'jrs,  Syd.  Soc.  Kd.  p.  2o9. 


I.ECT.  VIII.  SPURIOUS    COKTEAOTIONS.  255 

knuckle    of  intestine   intervenes    bet-vveen    the    liver   and   the 
abdominal  wall. 

d.  The  absence  of  other  signs  or  symptoms  of  real  disease  of 
tbe  liver.  The  possibility  of  there  being  ascites  independent 
of  hepatic  disease  niQst  be  kept  in  view. 

2.  General  or  partial  accumidations  of  gas  in  the  iJeritoneMl 
cavity,  such  as  may  result  from  perforation  of  the  stomach  or 
bowels,  may  obseoire,  to  a  greater  or  less  extent,  the  area  of 
hepatic  dulness ;  but  usually  the  nature  of  these  cases  will  be 
sufficiently  clear  from — 

a.  The  arched  tympanitic  distension  of  the  abdominal 
parietes ;  and 

6.  Antecedent  history  of  peritonitis  from  j)erforation. 

3.  The  hepatic  tissue  may  be  jpreternatiirally  soft,  so  that 
the  organ  may  fold  on  itself  and  collapse  against  the  spine  and 
the  back  part  of  the  abdomen,  and  be  covered  more  or  less  in 
front  by  the  stomach  and  bowels,  which  may  not  be  abnormally 
distended  with  gas.  I  have  already  pointed  out  to  you  that  in 
fatty  degeneration  the  enlargement  may  from  this  cause  appear 
to  be  increased,  a  larger  portion  than  natural  of  the  liver  beino- 
in  apposition  with  the  abdominal  wall  (p.  4S)  ;  but  if  the 
folding  be  carried  a  stage  further,  so  as  to  jDermit  the  super- 
position of  bowel,  a  contrary  result  may  take  place.  Lastly, 
in  acute  atrophy  of  the  liver  the  organ  is  not  only  reduced  in 
size,  but  it  may  be  so  soft  as  to  collapse  against  the  spine,  all 
trace  of  it  disappearing  from  the  abdominal  wall  in  front  so 
that  it  may  appear  smaller  than  it  really  is. 

Keeping  in  view  these  sources  of  fallac}',  which  are  T)erhaps 
more  calculated  to  mislead  than  the  sources  of  fallacy  in  the 
case  of  enlargement  (see  p.  7),  we  may  proceed  to  consider 
the  causes  of  real  atrophy  of  the  liver,  which  may  be  con- 
veniently arranged  under  the  three  following  heads  : 

I.  Simple  Atrophy. 
II.  Acute  Atrophy. 

III.  Chronic  Atrophy ;  under  Avhich  head  will  be  included 
the  disease  commonly  designated  '  Cirrhosis,'  '  Simple  Indu- 
ration,' and  '  Eed  Atrophy.' 

I  shall  now  endeavour  to  describe  to  you  the  leadino-  clinical 
characters  and  the  appropriate  treatment  of  these  several  forms 
of  atrophy. 


256  CONTEACTIONS    OF    THE    LIVER.  lkct.  vim. 

I.    SIMPLE    ATROPHY. 

By  '  simple  atropby  '  is  understood  a  diminution  in  the  size 
of  the  liver,  iu dependent  of  any  alteration  in  its  structure, 
except  a  diminished  size  of  the  lobules,  which  may  be  so  small 
as  to  be  distinguished  with  difficulty,  the  cut  surface  present- 
ing a  smooth  appearance  and  often  a  uniform  tint.  The  liver 
in  this  state  may  be  reduced  to  less  than  one-half  of  its 
normal  weight  and  bulk.  Although  this  condition  of  liver  is 
not  of  much  practical  importance,  more  or  less  of  it  is  far 
from  uncommon,  and  ignorance  of  its  nature  and  characters 
may  lead  to  errors  in  diagnosis.  You  will  recognise  this  form 
of  atrophy  then  by  the  following  characters  : — 

1.  The  circumstances  under  which  it  occurs.  These  are 
mainly  two,  viz.  Old  age  and  Inanition. 

a.  Old  Age — Simple  atrophy  has  been  sometimes  described 
as  '  senile  atroj^hy.'  With  the  advance  of  life,  the  tendency  of 
the  various  organs  and  tissues  throughout  the  body  is  either  to 
degenerate  or  to  waste.  In  some  persons  the  several  forms  of 
degeneration  (fatty,  calcareous,  &c.)  predominate ;  while  in 
others  we  observe  a  simple  wasting.  In  the  latter  case,  the 
power  which  prevailed  over  the  waste  of  the  body  in  childhood 
and  youth,  and  which  maintained  the  balance  in  the  vigour  of 
manhood,  has  failed,  and  waste  now  prevails  over  development. 
Considering  the  important  part  played  by  the  liver  in  the 
nutrition  of  the  bod}^  it  is  not  surprising  that  its  reduction  in 
old  age  is  in  advance  of  that  of  the  body  generally,  and  oc- 
casionally the  liver  is  reduced  by  senile  atrophy  to  one-half  of 
its  normal  size  and  weight. 

h.  Inanition  may  also  induce  simple  atrophy.  There  is 
little  or  no  supply-  to  compensate  for  the  constant  waste. 
When  you  remember  the  increase  in  the  bulk  of  the  liver 
produced  by  every  meal  (see  p.  I'U),  you  will  readily  under- 
stand how,  in  cases  of  inanition,  the  liver  often  wastes  out  of 
proportion  to  the  rest  of  the  body.  It  is  difficult  to  say  why  it 
is  that  the  effect  of  wasting  disease  is  in  some  persons  to  cause 
wasting  of  the  liver,  while  in  others  it  leads  to  the  accumulation 
in  the  organ  of  a  large  quantity  of  oil  (see  p.  51).  Inanition 
may  arise  in  two  wa^'s,  either  from,  an  insufficient  supply  of 
food  or  from  diseases  which  interfere  with  the  assimilation  of 
food.  Accordingly  you  will  find  simple  atro]")hy  of  the  liver 
extremely  common  in  the  bodies  of  persons  who  have  died  of 


LECT.  VIII.  SIMPLE    ATEOPHT.  257 

stricture  of  the  pylorus,  or  of  stricture  of  the  oesophagus  or  of 
the  cardiac  orifice  of  the  stomach.  I  shall  relate  to  you  imme- 
diately the  particulars  of  a  patient,  aged  54,  with  a  cancerous 
tumour  of  the  lower  end  of  the  oesophagus,  in  whom  the  area 
of  hepatic  dulness  was  reduced  to  one  half  of  the  normal 
standard,  and  whose  liver  after  death  was  found  to  weigh  only 
32  oz.,  instead  of  54  oz.,  the  average  weight  for  his  age  (Case 
CI.).  You  will  remember  also  the  case  of  Samuel  H.,  aged 
63,  who  died  of  a  cancer  of  the  oesophagus  involving  the  apex 
of  the  left  lung,  and  whose  liver  was  very  small  and  weighed 
only  42  oz. ;  and  the  case  of  Eliza  P.,  aged  48,  who  died  of 
cancer  of  the  pharynx  and  whose  liver  weighed  only  35  oz. 
All  these  were  good  examples  of  simple  atrophy. 

c.  External  Pressure  by  tight  lacing,  pleuritic  or  pericardial 
effusions,  circumscribed  peritoneal  exudations,  or  enlargement 
of  those  portions  of  the  bowel  nearest  to  the  liver,  may  likewise 
produce  simple  atrophy  of  the  liver.  The  atrophy,  however, 
under  these  circumstances  is  usually  partial  and  is  of  little 
clinical  importance,  unless  the  bile-ducts  or  large  blood-vessels 
have  been  subjected  to  the  pressure. 

2.  There  is  an  absence  of  any  sign  of  hepatic  disease  or  de- 
rangement. With  the  diminution  in  the  size  of  the  liver,  there 
is,  no  doubt,  a  loss  of  functional  power,  but  sufficient  secreting 
tissue  remains  for  the  diminished  work  to  be  done.  Care,  how- 
ever, 7Tiust  be  taken  not  to  mistake  for  symptoms  of  diseased 
liver  those  of  the  primary  disease  on  which  the  atrophy  de- 
pends. 

Simple  atrophy  of  the  liver  requires  no  special  treatment 
beyond  that  aolapted  to  the  circumstances  under  which  it 
occurs. 

The  following  case  will  serve  to  impress  on  your  memories 
the  clinical  characters  and  post-mortem,  appearances  of  simple 
atrophy  of  the  liver.  The  case  is  also  interesting  as  an  illus- 
tration of  cancerous  and  tubercular  deposit  taking  place  simul- 
taneously, of  which  other  examples  have  been  reported  by  Mr. 
Sibley,^  Dr.  Bristowe,^  and  myself.^  It  is  difficult  to  account 
for  these  cases  on  the  ordinarily  accepted  view,  that  tubercle 
anol  cancer  depend  on  a  *  peculiar  diathesis,'  regulating  the 
nature  of  the  exudation,  for  then  the  diathesis  must  vary  in 
different  parts  of  the  same  body. 

'  Med.  Chir.  Trans,  vol.  xlii.  p.  149.  -  Trans.  Path.  Soc.  vol.  x.  p.  2S4. 

3  Ibid.  vol.  XV.  p.  104. 
S 


258  CONTRACTIONS    OF   THE    LIYEE.  iect.  viii. 

Case  CI. — Co-  existence  of  Cancerous  Strichire  of  Q^sopJiagus  with  rece^it 
Tubercle  in  Lungs.     ISimple  Atrophy  of  Liver. 

Augustus  T ,  aged  54,  a  tailor,  adm.  into  Middlesex  Hosp.  on 

July  24,  1863.  He  was  of  average  height,  and  naturally  of  spare  habit. 
He  had  led  a  very  intemperate  life,  drinking  large  quantities  of  gin, 
but  he  had  always  enjoyed  good  health,  until  about  four  weeks  before 
admission,  when  he  began  to  suffer  from  sickness,  comiug  on  immedi- 
atelv  after  eating,  sometimes  even  before  he  thought  the  food  had  been 
swallowed.  He  had  never  observed  blood  in  the  vomited  matters,  but 
he  had  rapidly  lost  both  flesh  and  strength. 

On  admission,  very  emaciated  ;  an  anxious  expression  of  counte- 
nance. He  could  swallow  solid  food  ;  but  it  was  usually  rejected,  either 
immediately  or  within  a  few  minutes.  He  also  brought  up  from 
time  to  time  large  quantities  of  clear  acid  fluid.  He  complained  of 
pain  between  shoulders,  but  there  was  no  tenderness  of  spine,  and  no 
abnormal  physical  sign  in  either  lung.  Abdomen  nowhere  tender,  and 
nothing  like  a  tumour  could  be  felt  in  any  part  of  it.  Hepatic  dulness 
much  diminished,  not  exceeding  2^  inches  in  right  mammary  line. 
Splenic  dulness  normal ;  no  ascites  or  jaundice.  Tongue  furred ; 
bowels  costive.  Pulse  61  and  feeble  ;  no  abnormal  bruit  over  heart ; 
no  anasarca  ;  no  albumen  in  urine. 

All  remedial  measures  failed  to  relieve  the  vomiting,  and  patient 
got  rapidly  thinner  and  weaker,  while  hepatic  dulness  was  reduced  to 
2  inches.  Oa  Aug.  30,  vomiting  abated,  but  this  was  due  to  patient's 
taking  scarcely  any  nourishment.  He  died  on  Sept  7.  At  no  period 
of  his  illness  had  he  cough ;  lungs  not  examined  after  July  24. 

Autrq^sij. — Entire  absence  of  fat  beneath  integuments  and  throughout 
body.  Oesophagus,  1^  inch  above  cardia,  had  its  calibre  narrowed  to 
that  of  a  goose-quill  for  about  half-an-inch.  A  hard  tumour,  size  of 
half  a  walnut,  was  firmly  attached  to  constricted  portion,  and  formed 
part  of  its  posterior  wall  ;  mucous  membrane  con-esponding  to  tliis 
presented  a  puckered  cicatrix-like  aj)pearance.  Substance  of  tumour 
dense,  fibrous,  white,  and  slightly  translucent,  and  dotted  over  with 
softer,  more  opaque,  yellow  specks.  It  yielded  an  opaque  juice  on 
scraping.  On  microscopic  examination,  the  firmer  portions  of  tumour 
were  found  to  contain  numerous  '  cancer  cells,'  varying  in  size  up  to 
^Jjy  inch  in  diameter.  They  were  rounded,  elliptical,  and  caudate,  and 
contained  one  or  two  large  nuclei  with  a  diameter  about  one-third  of  that 
of  cell.  Some  of  cells  had  smaller  cells  in  their  interior.  In  softer 
portions  of  the  tumour,  cells  were  ill-defined  and  mixed  with  much 
oily  and  granular  matter.  Neither  bronchial  glands,  nor  lymphatics 
in  neighbourhood  of  tumour  were  enlarged.  Stomach  small,  but 
otherwise  normal.  Liver  presented  ordinary  characters  of  simple 
atrophy  ;  it  weighed  only  32  ounces ;  its  outer  surface  was  smooth ; 
only  abnormal  appearance  seen  on  section  was  that  acini  were  reduced 


LECT.  VIII.  ACUTE    ATROPHY.  259 

to  one  half  of  tlieir  usual  size ;  secreting  cells  were  small,  and  con- 
tained scarcely  any  oil,  but  were  otherwise  normal.  Spleen  weighed 
only  three  ounces  ;  kidneys  were  also  small  and  anaemic,  but  in  other 
respects  normal. 

Both  lungs  were  very  small,  right  weighing  9^  ounces,  and  left  8| 
ounces.  Apices  of  both  were  firmly  adherent  to  thoracic  walls,  and 
marked  externally  with  cicatrices.  Several  cretified  deposits  as  large 
as  peas,  as  well  as  one  or  two  small  cavities  with  thick  walls  and  con- 
taining pus,  were  disclosed  on  cutting  into  cicatrices.  Scattered 
through  upper  lobes  of  both  lungs  were  a  number  of  translucent 
greyish  granules,  isolated  and  collected  into  groups,  as  large  as  a  hazel- 
nut, and  presenting  all  the  naked-eye  and  microscopic  characters  of 
miliary  tubercles.  Heart  weighed  only  6J  ounces,  and  was  destitute 
of  fat,  but  in  other  respects  was  normal. 

II.    ACUTE    OR   TELLOW    ATROPHY.       *  MALiaNANT,'     '  TYPHOID,'    OR 
'  HEMORRHAGIC    JAUNDICE.' 

This  is  a  rare  but  very  remarkable  disease,  in  which  the  liver 
becomes  rapidly  atrophied  with  the  development  of  jaundice 
and  cerebral  symptoms,  and  where  after  death  what  remains 
of  the  organ  is  found  to  be  extremely  soft  and  yellow,  with  no 
appearance  of  lobules,  and  with  the  secreting  cells  in  a  great 
measure,  or  wholly,  broken  up  into  granular  matter  and  oil- 
globules.  The  rarity  of  the  disease  in  this  city  is  attested  by  the 
fact,  that  although  a  brown  tongue  and  delirium  formerly  con- 
stituted a  certain  passport  for  the  transmission  of  all  diseases 
to  the  London  Fever  Hospital,  out  of  about  25,700  cases  ad- 
mitted during  nine  years,  I  believe  that  the  only  example  of 
the  disease  which  was  noticed  was  one  of  which  I  shall  narrate 
to  you  the  particulars  immediately.  The  disease,  however,  is 
one  of  the  most  interesting  that  can  engage  your  attention, 
and  may  be  recognised  by  the  following  clinical  characters : — 

1.  Premonitory  symptoms  are  noticed  in  many  cases,  but 
they  are  usually  slight  and  variable  in  their  nature  and  they 
are  sometimes  absent.  The  most  common  are  those  of  gastro- 
enteric catarrh,  such  as  furred  tongue,  nausea  and  loss  of 
appetite,  occasional  vomiting  and  irregular  bowels — diarrhoea 
or  constipation,  and  slight  pyrexia.  At  other  times,  the 
patient  complains  only  of  rheumatic  pains,  of  an  uneasy  sensa- 
tion in  the  region  of  the  heart  or  stomach,  or  of  a  feeling  of 
uneasiness  which  he  is  unable  to  define.  These  synjptoms  may 
last  three  or  four  days,  or  as  many  weeks,  but  withal  there  is 

s  2 


26o 


CONTEACTIONS    OF    THE    LIVER. 


not,  as  a  rule,  thought  to  be  much  amiss,  while  in  not  a  few 
cases  the  patient  has  no  feeling  of  indisposition  until  the  super- 
vention of  symptoms  of  a  more  decided  character. 

2.  Jaundice  is  invariably  present,  and  is  usually  the  first 
svmptom  that  attracts  attention  to  the  patient's  condition. 
The  jaundice,  however,  is  rarely  intense,  and  is  sometimes 
confined  to  the  upper  part  of  the  body.  Like  the  jaundice  of 
pycemia  (see  p.  105)  it  appears  to  be  due  to  a  morbid  condition  of 
the  blood,  and  is  independent  of  any  obstruction  of  the  bile-duct, 
and  bile  is  found  throughout  in  the  stools.     (See  Lect.  XI.) 

3.  A  rapid  diminution  in  the  area  of  hepatic  dulness  is  one 
of  the  most  remarkable  features  of  the  disease.  In  the  course 
of  a  week  or  ten  days,  one-third,  or  even  more  than  one-half 
of  the  liver  may  disaj)pear  (see  fig.  23).  Bright  has  recorded 
a  case  where  the  liver  after  death  weighed  only  nineteen  ounces, 


Fig.  ?,3.     Area  of  Hepatic  Dulness  in  ]\Iary  Ann  M (Case  CII.),"on  the 

day  before  death. 

and  its  weight  in  one  case  which  I  shall  bring  under  your 
notice  was  only  twenty-eight  ounces.  It  must  not,  however,  be 
inferred  that  a  diminished  area  of  hepatic  dulness  is  necessary 
for  the  diagnosis  of  the  disease  known  as  '  acute  atrophy.'  It 
may  happen  that  the  liver  has  been  enlarged  by  previous 
disease  (Case  CIII.) ;  but  independently  of  this,  a  considerable 
number  of  cases  have  been  observed  in  which  the  liver  at  the 
commencement  of  the  morbid  process,  and  consequent  upon  it, 


LECT.   Till. 


ACUTE    ATEOPHY.  261 


has  been  found  to  be  considerably  increased  in  size.  Lieber- 
meister  ^  and  Trousseau  ^  refer  to  cases  of  this  sort ;  and 
similar  observations  liave  been  made  by  Sieveking-,^  TMoxon,* 
Tuckwell/  &c.  Still,  even  in  these  cases,  the  preliminary 
enlargement  is  followed,  if  the  case  be  sufficiently  prolonged,  by 
a  rapid  diminution  in  the  size  of  the  liver.  It  has  been  lately 
suggested  that  the  a.trophy  in  these  cases  is  a  chronic  process, 
though  unattended  by  symptoms  until  the  final  explosion  ;  but 
this  view  is  opposed  by  most  of  the  known  facts  in  reference  to 
the  etiology  of  the  disease,  and  also  by  the  circumstance  that  it 
may  be  ascertained  by  percussion  that  the  atrophy  is  going  on 
during  life.  Careful  examination  of  the  gland  after  death 
shows  that  the  atrophy  is  due  to  a  destructive  process  com- 
mencing at  the  circumference  of  the  lobules  and  advancing  to 
the  centre,  as  the  result  of  which  the  secreting  cells  disappear 
and  in  their  place  we  find  nothing  but  granular  matter  and 
oil.  The  disease,  in  fact,  is  believed  to  be  nothing  more  nor 
less  than  an  acute  fatty  degeneration  of  the  liver,  resulting 
from  a  difi'use  inflammatory  process ;  for,  previous  to  bursting, 
the  cells  may  often  be  seen  distended  with  oily  and  granular 
contents.  During  life  the  atrophy  of  the  liver  may  apj)ear 
greater  than  it  really  is,  because  the  gland  is  not  only  reduced 
in  size,  but  also  softened,  so  that  it  folds  upon  itself  and  col- 
lapses towards  the  vertebral  column,  the  space  corresponding  to 
it  in  front  being  occupied  by  intestines  containing  gas. 

4.  Pain  at  the  epigastrium  and  in  the  region  of  the  liver  is 
present  in  most  cases.  This  pain  often  comes  on  spontaneously, 
and  can  almost  always  be  elicited  by  pressure,  even  when  the 
patient  is  almost  unconscious.  There  is  rarely,  however,  any 
tympanitic  distension  of  the  abdomen,  unless  there  be  (as  in 
Case  CII.)  concurrent  peritonitis,  in  which  case  the  pain  and 
tenderness  may  be  acute.  Muscular  and  arthritic  pains  are 
also  not  uncommon  and  occasionally  the  joints  seem  swollen  ; 
while  some  patients  complain  of  suffocative  sensations,  or  there 
is  dyspnoea  not  accounted  for  by  any  lesion  in  the  heart  or 
lungs. 

5.  Vomiting  occurs  in  most  cases,  the  vomited  matters 
consisting  of  the  ingesta  mixed  with  mucus  or  bile,  but  often 
also  containing  much  blood,  and  resembling  the  '  black  vomit ' 

>  Virohow's  Jahresbericht,  1870,  ii.  165. 

2  Clin.  Med.,  Syd.  Soc.  Ed.  iv.  299,  308.  *  Path.  Trans,  vol.  xxiii. 

»  Lancet,  1872,  ii.  224.  *  Earth.  Hosp.  Eep.  vol.  x. 


262  CONTRACTIONS    OP   THE    LIVER.  lect.  vui. 

of  yellow  fever.  The  bowels  are  described  as  being  usually 
constipated,  but  in  the  case  from  which  this  liver  was  taken 
(Case  CII.)  there  was  a  considerable  amount  of  diarrhoea.  The 
stools  in  the  first  instance  are  often  pale,  but  in  other  cases 
they  contain  bile  ;  in  the  advanced  stage  they  not  unfrequently 
contain  blood  and  are  very  offensive. 

6.  The  area  of  splenic  dulness  is  usually  increased,  except 
in  cases  where  the  portal  system  has  been  drained  by  diarrlioea 
or  by  hasmorrhage  from  the  stomach  or  bowels. 

7.  The  cerebral  symptoms  of  the  'typhoid  state'  constitute 
one  of  the  most  frequent  and  striking  peculiarities  of  acute 
atrophy.  As  a  rule,  they  appear  simultaneously  with  the 
jaundice,  but  occasionally  not  for  two  or  three  weeks  subse- 
quently, the  jaundice  at  first  having  all  the  characters  of  what 
is  commonly  known  as  '  catarrhal.'  At  first  there  is  headache, 
with  despondency,  irritability,  and  great  restlessness  ;  and  this 
condition  is  succeeded  by  low  muttering  delirium,  tremors, 
subsultus,  muscular  rigidity  and  carphology,  retention  or  in- 
continence of  urine,  involuntary  passage  of  fseces,  stupor,  coma 
and  convulsions.  These  symptoms  are  said  to  be  sometimes 
associated  with  fatty  disintegration  of  the  cerebral  tissue,  but, 
like  the  analogous  symptoms  in  typhus  fever  and  in  the  typhoid 
state  generally,  to  which  I  have  directed  your  attention  on  a 
former  occasion,'  they  probably  result  from  the  circulation 
through  the  brain  of  blood  poisoned  by  the  accumulation  in  it 
of  urea  and  other  products  of  tissue-metamorphosis  which 
ought  to  be  eliminated  by  the  kidneys. 

8.  Acute  atrophy  of  the  liver  is  not  attended  by  pyrexia. 
The  pulse  varies.  In  cases  ushered  in  with  gastro-enteric 
catarrh  the  pulse  is  usually  accelerated  at  first,  but  falls  to  the 
normal  standard,  or  below  this,  on  the  appearance  of  jaundice, 
and  again  rises  on  the  supervention  of  cerebral  symptoms,  its 
frequency  often  varying  at  different  hours  of  the  day.  In  Case 
CII.  it  rose  to  as  high  as  144,  but  here  there  was  peritonitis. 
The  temperature  in  the  early  stage  of  the  disease  may  be 
slightly  elevated,  but  it  rarely  much  exceeds  101°.  But  when 
the  symptoms  are  well  pronounced,  the  temperature  is  usually 
not  elevated,  and  sometimes  it  is  subnormal.  In  Case  CIII.  it 
fell  to  as  low  as  95*5°  and  a  similar  observation  has  been  made 


'  On  the  Patliolopy  and  Treatment  of  the  Typhoid  State  in  different  Diseases. 
Abstract  of  Lecture  in  IJrit.  Med.  Journ.  Jan,  4,  JSG8. 


LECT.  Tin.  ACUTE    ATROPHY.  263 

by  Duckworth.^  The  temperature  of  101°  noted  shortly  before 
death  in  Case  CII.  was  probably  due  to  the  peritonitis.  This 
absence  of  pyrexia  is  of  the  utmost  importance  in  the  diagnosis 
of  acute  atrophy  from  other  diseases  characterised  by  the 
typhoid  state.  After  the  appearance  of  cerebral  symptoms,  the 
tongue  is  almost  invariably  dry  and  brown,  and  the  teeth 
crusted  with  sordes,  exactly  as  in  a  bad  case  of  typhus  fever. 

9.  The  urine  undergoes  important  changes.  Its  quantity  is 
not  materially  altered ;  it  is  of  acid  reaction ;  and  its  specific 
gravity  varies  from  1012  to  1024.  Its  colour  is  usually  dark, 
but  the  ordinary  reaction  of  bile-pigment  may  be  faint  or  in- 
distinct. It  often  contains  albumen  or  even  blood ;  but  after 
the  removal  of  the  urinary  pigment,  it  yields  no  reaction  of 
bile-acids  to  Petteukofer's  test.  The  most  remarkable  altera- 
tions, however,  consist  in  the  great  diminution  or  even  total 
disappearance  of  the  urea  and  uric  acid,  and  also  of  the 
chlorides,  sulphates,  and  earthy  phosphates,  and  the  substitution 
of  two  new  substances  of  a  peculiar  nature,  leucin  and  tyrosin. 
These  substances  are  products  of  the  metamorphosis  of  nitro- 
genous matter  intermediate  between  the  protein  principles 
(albumen  and  fibrin)  at  one  extreme,  and  the  less  coDiplex 
bodies,  urea,  uric  acid,  kreatin,  &c.  at  the  other,  as  will  be 
seen  by  a  comparison  of  the  following  formulte : — 

Albuminoids  =  C72H,i2Ni8S023 
Tyrosin  =  CgHnISrOg 

Leucin  =  CcHigN'Oa 

Uric  Acid      =  C,,H4N4  03 
Urea  =  CHRIS'S  0 

Leucin  and  tyrosin,  in  the  crystalline  forms  represented  in 
the  annexed  figures  (figs.  24,  25,  and  26),  are  found  in  the 
tissues  of  the  liver,  spleen,  and  kidneys  in  cases  of  acute  atrophy, 
and  they  are  usually  also  secreted  in  large  quantity  in  the  urine, 
from  which  they  separate  as  a  distinct  deposit  on  standing,  or 
they  may  be  obtained  by  evaporating  a  few  drops  of  the  urine, 
on  a  glass  slide. ^     The  detection  of  these  crystalline  bodies  in 

'  Earth.  Hosp.  Eep.  vol.  vii.  Briglit  and  Alison  long  ago  noted  that  the  skin 
was  cool. 

-  Tests  for  Leucin  and  Tyrosin.  A.  For  Leucin.  Concentrate  urine  and  dissolve 
in  alcohol.  Evaporate  alcoholic  solution  and  dissolve  in  water,  from  which  the 
leucin  ought  to  crystallize  in  spherical  globes.  B.  For  Tyrosin.  1.  Hoffmann's  Test ^ 
A  solution  of  the  nitrate  of  the  protoxide  of  mercury,  nearly  neutral,  is  to  be  added  to 
the  suspected  solution.     If  tyrosin  be  present,  a  reddish  precipitate  is  produced,  and 


264 


CONTRACTIONS    OF    THE    LIVER. 


LECT.   VIII. 


the  urine  of  a  case  of  jaundice  may  be  said  to  clencli  tlie 
diagnosis  of  acute  atrophy  of  the  liver,  but  the  failure  to  detect 
them  must  not  exclude  acute  atrophy  from  the  diagnosis.  For 
instance,  they  were  not  present  in  the  urine  of  Case  CII.,  at  all 
events  in  such  quantity  as  to  reveal  their  existence  by  simply 
evaporating  the  urine,  although  they  were  found  in  consider- 


..Ui^""-'-/o 


Fig.  24.    Microscopic  needle-shaped  crys-         Fig.  2.').     Microscopic  glolnilar  mapses 
tals  of  tyrosin  adhering  in  bundles  and  composed  of  acicular  crystals  of  ty- 

in  stellate  groups.  rosin. 

able  quantity  in  the  liver  and  kidneys  after  death.  It  is  true 
that  in  this  case  death  was  accelerated  by  acute  peritonitis ; 
had  the  patient  survived  a  little  longer,  leucin  and  tyrosin 
would  probably  have  been  found  in  the  urine. 


Fig.  26.     Microscopic  laminated  crystalline  masses  of  leucin. 

10.  Haemorrhages  are  very  common,  and  particularly 
haemorrhage  from  the  stomach,  bowels,  or  nose.  Blood  is  often 
vomited  in  large  quantit3\  Petechise,  purpura-spots,  and 
vibices  often  appear  on  the  slcin,  or  in  rarer  cases  there  is  uterine 
haemorrhage.  After  death  ecchymoses  are  found  in  different 
parts  of  the  body.     From  the  frequency  of  these  hajinorrhages 

the  supernatant  lif|nid  is  of  a  dark  rose  colour.  2.  Freric/is  Test.  Add  U)  suspected 
liquid  a  solution  of  acetate  of  lead  until  no  more  precipit;ite  is  produced.  .Sulphur- 
etted hydrogen  gas  is  then  to  be  passed  through  tlie  filtered  fluid.  Separate  the  sul- 
phurot  of  lead  by  filtration,  and  concentrate  the  clear  solution  by  evaporation,  -when, 
if  tyrosin  be  present,  it  will  crystallise  out  as  long  white  needles. 


LECT.  VIII.  ACUTE    ATROPHY.  265 

tlie    disease    has   been    sometimes    designated    '  hsemorrhagic 
jaundice.' 

11.  Pregnant  females,  who  constitute  a  large  proportion  of 
the  cases,  almost  invariably  abort  or  miscarry  before  dying. 

12.  The  circumstances  under  which  acute  atrophy  of  the 
liver  occurs  constitute  not  the  least  interesting  part  of  its 
clinical  history.  The  causes  of  the  disease  still  require  inves- 
tigation, but  I  shall  briefly  mention  those  that  are  at  present 
known.     Among  predisposing  causes,  then,  we  have — 

a.  Age.  Most  persons  attacked  with  the  disease  are  under 
the  middle  age.  Of  31  cases  collected  by  Frerichs,  26  were 
under  30,  and  all  but  2  under  40.  Of  4  cases  which  have  come 
under  my  notice,  two  were  females,  aged  19  and  30 ;  and  two 
were  males,  aged  2l<  and  62;  in  a  fifth  case  (Case  CIIL),  where 
the  disease  was  secondary  to  obstruction  of  the  bile-duct,  the 
patient  was  a  male,  aged  66.  All  writers  agree  as  to  the  rarity 
of  the  disease  in  children.  ITeither  Niemeyer,  Prerichs,  nor 
Trousseau  ever  met  with  the  disease  in  early  life.  West,  in 
his  extensive  experience,  has  only  seen  the  disease  once,  in  a 
girl  aged  4^  years ;  but  three  other  cases  in  children  have  been 
recorded  by  Duckworth '  and  Tuckwell.^ 

h.  Sex.  The  disease  is  much  more  common  in  females 
than  in  males.  -Of  the  31  cases  collected  by  Frerichs,  22  were 
females. 

c.  Pregnancy  must  be  regarded  as  a  predisposing  cause,  for 
of  the  22  female  patients  referred  to  by  Frerichs,  one  half  were 
attacked  while  pregnant.  Prom  the  third  to  the  sixth  month 
is  the  most  common  period  of  pregnancy  at  which  the  disease 
shows  itself.  In  the  pregnant  state  it  is  said  to  be  frequently 
associated  with  fatty  degeneration  of  the  kidneys  and  albumi- 
nous urine. 

d.  Dissipation,  including  drunkenness  and  venereal  excesses, 
precedes  the  disease  in  a  considerable  number  of  cases.  Leudet 
is  of  opinion  that  its  origin  maj'  sometimes  be  traced  to  the 
absorption  of  a  large  quantity  of  undiluted  alcohol.  ^ 

e.  Constitutional  syphilis  appears  to  be  a  predisposing 
cause  in  some  cases.  Most  writers  on  syphilis  have  noted  the 
frequent  occurrence  of  jaundice  about  the  commencement  of 
what  is  known  as  the  secondary  stage  ;  in  most  cases  the  con- 
stitutional symptoms  are  slight  and  the  jaundice  soon  passes 

'  Loc.  cit.  2  Log_  cit.  =  Clin.  Medicale,  Paris,  1874,  p.  67. 


266  CONTRACTIONS    OF   THE    LIVER.  lect.  viii. 

away  (p.  153)  ;  but  now  and  then  what  appears  to  be  at  first 
a  slight  catarrhal  jaundice  becomes  rapidly  developed  into  the 
symptoms  of  acute  atrophy.' 

Among  causes  that  appear  to  act  more  directly  in  exciting 
the  disease  are  the  following : — 

a.  Nervous  influences,  such  as  severe  mental  emotions,  and 
particularly  anxiety,  fear,  and  grief.  Sir  Thomas  Watson,  in 
his  lectures,  states  that  scores  of  instances  are  on  record,  where 
jaundice  has  suddenly  appeared  under  such  circumstances,  and 
adds  that  'these  cases  are  often  fatal,  with  head  symptoms, 
convulsions,  delirium,  or  coma,  supervening  upon  the  jaundice.'^ 
In  these  cases  an  impression  made  upon  the  nervous  system 
may  be  directed  to  the  liver  and  derange  its  nutrition,  or 
perhaps  more  probably  it  excites  in  the  first  instance  morbid 
changes  in  the  blood. 

h.  Malaria.  There  are  other  cases  where  the  disease  has 
apparently  resulted  from  some  malarious  poison,  acting  probably 
through  the  blood  and  the  nervous  system.  Instances  have 
been  recorded  by  Graves,^  Budd,''  and  others,  where  several 
cases  of  what  appears  to  have  been  unquestionably  this  disease 
occurred  in  the  same  house,  or  where  it  has  been  even  epidemic 
in  certain  localities  (See  Lecture  XI.)  ;  and  when  it  is  considered 
what  a  rare  disease  acute  atrophy  is,  it  is  impossible  to  escape 
from  the  conclusion  that  in  these  cases  there  must  have  been 
some  local  cause  to  which  all  the  patients  were  subjected  in 
common. 

c.  The  blood-poisons  of  typhus  fever  and  allied  diseases  have 
been  known  to  give  rise  to  acute  atroj)hy  of  the  liver.* 
Jaundice  is  a  very  rare  complication  of  typhus  and  scarlet 
fever,  but  in  more  than  one  instance  where  it  has  occurred,**  I 
have  found  crystals  of  leucin  and  tyrosin  in  the  tissue  of  the 
liver  and  kidney.  The  liver  in  these  cases  has  been  in  a  state 
of  fatty  degeneration,  but  without  marked  atrophy.  Most 
writers  on  the  yellow  fever  of  the  tropics  have  described  latty 
degeneration  of  the  liver  as  one  of  its  most  characteristic 
lesions,  and  it  is  well  known  that  there  is  a  deficient  elimination 

'  See  LeVjert  in  Vircliow's  Arcliiv,  18;)4,  hSoo;  Andri'M',  in  Path.  TraiiB.  xvii.  p. 
158;  aud  Faggo,  lb.  xviii.  p.  138. 

*  Locturcs  on  tlio  Practice  of  Physic,  5th  od.  ii.  p.  G8'2. 
'  Clin.  Lcct.  2nd  ed.  ii.  p.  255. 

♦  Op.  cit.  3rd  od.  pp.  255,  270. 

*  See  Frericlis'  Tre.itiso  on  Diseases  of  Livor,  Sy<l.  Soc.  Ed.  i.  p.  235. 

•  Treatise  on  the  Coutiuuod  Pevers  of  Great  Eritaiu,  2nd  ed.  p.  210. 


LECT.  VIII. 


ACUTE    ATEOPHT.  26/ 


of  urea;  but  observations  are  still  wanting  as  to  the  presence  or 
absence  of  leucin  or  tyrosin  in  the  urine  and  in  the  tissues  of 
the  kidneys  and  liver. 

d.  Phosphorus  occasionally  produces  symptoms  and  struc- 
tural changes  in  the  liver  very  similar  to,  if  not  identical  with, 
those  of  acute  atrophy  of  the  liver.     (See  Lect.  XI.) 

e.  Lastly,  it  seems  not  improbable  that  in  some  cases  of 
acute  atrophy  the  cause  may  be,  as  suggested  by  Dr.  Budd  ' 
and  Trousseau,^  some  special  poison  engendered  in  the  body 
itself  by  faulty  digestion  or  assimilation.  The  nervous  in- 
fluences already  referred  to  may  possibly  contribute  to  the 
development  of  such  a  poison.  It  is  probably  also  in  this  way 
that  acute  atrophy  sometimes  supervenes  upon  other  diseases 
of  the  liver.  According  to  Trousseau,  malignant  jauudice  is 
'  never  caused  by  obstruction  of  the  biliary  ducts ; '  ^  but  this 
assertion  is  negatived  by  what  was  observed  in  Case  CIII. 
During  a  prevalence  of  epidemic  catarrhal  jaundice  it  has 
frequently  been  found,  that  while  the  majority  of  the  patients 
have  recovered  without  any  bad  symptoms,  a  few,  at  first  in  no 
way  to  be  distinguished,  have  been  followed  by  acute  atrophy. 
A  similar  observation  has  been  made  in  the  catarrhal  jaundice 
resulting  from  syphilis. 

It  would,  ind-eed,  be  remarkable  that  all  these  causes  should 
single  out  the  liver  for  special  destruction;  but  in  a  future 
lecture  I  will  show  you  that  the  liver  is  far  from  being  the 
only  organ  that  undergoes  disintegration,  and  that  in  fact  the 
disease  known  as  '  acute  atrophy  of  the  liver '  is  more  probably 
a  general  than  a  local  disease.     (See  Lect.  XL) 

Treatment. — In  acute  atrophy  of  the  liver  all  treatment  has 
hitherto  proved  unsatisfactory.  The  disease,  after  the  super- 
vention of  cerebral  s^^mptoms,  is  in  most  cases  fatal,  although 
well  authenticated  instances  are  on  record  where  patients  have 
recovered  after  falling  into  a  state  bordering  on  coma.  It  may 
be  well,  therefore,  to  enumerate  those  remedial  measures  which 
have  appeared  most  useful,  or  which  seem  indicated  by  our 
knowledge  of  the  pathology  of  the  disease. 

1.  Purgatives.  In  several  instances  which  have  been  re- 
ported as  occurring  in  Ireland,  patients  in  the  same  house  with 
others  who  have  died  have  recovered  after  active  purging  in 

'  Op.  cit.  p.  265.  -  Op.  cit.  p.  319.  »  Qp.  cit.  p.  317. 


268  CONTEACTIONS    OF    THE    LIVEK.  lect.  viii. 

conjunction  witli  leeches  and  blisters  to  the  head.'  Even  in 
fatal  cases  temporary  improvement  has  often  followed  smart 
purgation.  Dr.  Budd  also  states  that  in  several  cases  he  had 
found  advantage  from  a  combination  of  sulphate  of  magnesia 
(5J),  carbonate  of  magnesia  (gr.  xv),  and  spiritus  ammonias 
aromaticus  (5ss)  given  three  times  a  day. 

2.  After  the  supervention  of  cerebral  symptoms,  all  measures 
calculated  to  promote  the  elimination  of  urea  and  uric  acid  or 
of  other  products  of  disintegrated  tissue  from  the  system 
deserve  a  trial.  It  is  in  this  way  perhaps  that  purgatives  have 
23roved  beneficial,  and  that  warm  baths,  hot  air  baths,  dia- 
phoretics, diuretics,  and  colchicum  may  also  be  expected  to  do 
good. 

3.  In  cases  where  there  is  extensive  haemorrhage  from  the 
stomach  or  from  other  'mucous  membranes,  ice  or  astringents 
may  be  necessary. 

4.  It  is  in  the  early  stages,  however,  of  the  malady,  before 
the  occurrence  of  cerebral  symptoms,  that  most  advantage  may 
be  expected  from  treatment.  Cheering  society,  holding  out 
hopes  of  recovery,  change  of  scene,  anodynes  to  procure  sound 
sleep,  attention  to  the  condition  of  the  stomach  and  bowels, 
and  ammonia  and  alkalies  with  the  infusion  of  gentian  or 
some  other  vegetable  bitter,  are  the  measures  which  appear 
best  calculated  to  avert  those  terrible  cerebral  symptoms  from 
which  so  few  recover. 

The  liver,  which  I  show  you  here,  was  taken  from  the  body 
of  a  patient  who  died  some  years  ago  in  the  London  Fever 
Hospital,  and  who  presented  the  symptoms  of  acute  atrophy  of 
the  liver  in  a  typical  form,  excepting  that  no  leucin  or  ty rosin 
was  found  in  tlie  urine  passed  the  day  before  death.  These 
substances,  however,  were  detected  after  death  in  the  tissue  of 
the  liver  and  kidneys,  and  the  former  of  these  organs  pre- 
sented all  the  anatomical  characters  peculiar  to  the  disease. 
It  may  be  worth  mentioning,  however,  that  both  Dr.  Cay  ley 
and  myself  failed  to  find  either  leucin  or  tyrosin  in  the  fresh 
liver  and  kidneys,  although  they  were  present  in  large  quan- 
tity after  these  organs  had  been  immersed  for  some  days  in 
spirit. 

'  See  cases  Ly  Dr.  W.  Griffin,  of  Limerick,  in  Dub.  Joiiru.  of  Mod.  and  C'..cm. 
Science,  1834,  and  by  Dr.  llanlon,  in  Graves,  loc.  cit. 


LECT.  vm.  ACUTE    ATROPHY.  269 

Case    Oil. — Acute    Atrophj   of  Liver — Acute  Peritonitis — Leucin   and 
Tyrosin  in  Liver  and  Kidneys,  but  none  detected  in  Urine. 

Mary  Ann  M ,   a  sempstress,  aged  19,  admitted  into  London 

Fever  Hospital,  on  evening-  of  Feb.  13,  1868,  and  seen  by  me  on  fol- 
lowing morning.  She  was  -unmarried.  Her  father  was  a  German, 
but  she  bad  been  born  and  brought  up  in  London.  Her  sister  was  not 
aware  that  she  had  suffered  from  any  mental  trouble,  and  believed  that 
her  catamenia  had  been  regular;  there  Avas  no  history  of  syphilis. 
There  bad  been  no  other  case  of  illness  in  the  house  from  which 
she  came.  She  had  been  quite  well  until  middle  of  January,  when 
she  began  to  complain  of  loss  of  appetite  and  nausea,  and  after  ten 
days,  her  skin  was  noticed  to  be  slightly  yellow.  A  W6ek  before  ad- 
mission she  took  to  bed,  complaining  of  pain  in  region  of  stomach, 
aggravated  by  any  movement,  but  unattended  by  vomiting.  For 
about  a  fortnight  before  admission  bowels  had  been  relaxed  three  or 
four  times  a  day,  motions  at  first  being  yellow,  but  latterly  green. 
Three  days  before  admission  she  began  to  be  '  light-headed.' 

On  morning  after  admission  the  following  note  was  taken  : — • 
'  Patient  is  a  well-nourished  girl,  and  has  deep  jaundice  of  skin  and 
conjunctivEe.  Is  scarcely  conscious,  and  can  give  no  account  of  her- 
self. Since  admission  has  been  very  restless  and  delirious,  often 
screaming  out  loudly.  Pupils  much  dilated,  but  equal,  l^o  eruption 
on  skin,  which  feels  dry  and  hot,  temperature  in  the  asilla  being  101°  F. 
Pulse  116  and  weak.  Cardiac  and  respiratory  signs  normal.  Tongue 
dry  and  brown,  and  since  admission  there  has  been  frequent  vomiting 
of  a  dark  brownish  fluid  evidently  containing  blood.  Bowels  have 
acted  several  times,  and  from  nurse's  account,  who  describes  motions 
as  very  dark,  watery,  and  offensive,  they  have  probably  contained 
blood.  Abdomen  moderately  distended  and  tympanitic ;  pressure 
upon  it  does  not  seem  to  cause  pain,  but  respiration  is  thoracic,  and 
tliere  is  an  obscure  thrill,  as  from  fluid,  on  tapping  both  flanks. 
Hepatic  dulness  is  greatly  diminished,  not  exceeding  1;|-  inch  in  right 
mammary  line,  and  its  lower  margin  being  fully  2  inches  above  that 
of  ribs  (se  fig.  23,  p.  260).  Ui'ine  has  been  passed  in  bed,  but  bladder 
is  now  full.' 

About  two  pints  of  urine  were  drawn  ofi"  by  catheter,  which  had 
the  following  characters.  It  was  acid;  specific  gravity  1015;  of  a 
dark  greenish-brown  colour,  but  presenting  reaction  of  bile-pigment 
in  only  a  faint  degree.  Heat  produced  no  change  on  it,  but  on  adding 
nitric  acid,  after  boiling,  it  became  turbid,  as  well  as  very  dark.  ISTi- 
trate  of  urea  could  be  obtained  from  it  in  only  very  small  quantity,  but 
no  crystals  of  leucin  or  tyrosin  could  be  detected,  either  as  a  separate 
deposit  on  standing,  or  after  evaporation  of  a  few  drops  of  urine  in  a 
watch-glass.  Unfortunately  urine  was  thrown  away  before  it  could  be 
submitted  to  a  more  careful  analysis. 


2/0  CONTRACTIONS    OF    THE    LIVER.  lect.  viii. 

Patient  was  ordered  a  mixture  containing  nitric  acid,  nitrous  etlier, 
and  nitrate  of  potash,  with  milk,  beef-tea,  and  four  ounces  of  gin.  She 
became  rapidly  worse,  although  she  was  less  noisy  and  delirious,  and 
seemed  to  sleep  a  good  deal  at  intervals.  Diarrhoea  continued,  motions 
being  passed  in  bed,  and  being  still  liquid  and  very  offensive,  but  of 
a  light  yellow  colour.  In  evening  of  14th,  pulse  1-44;  respiration 
32  and  thoracic ;  temperature  in  axilla  100'8°.  She  continued  much 
in  same  state,  and  died,  without  any  convulsions,  at  7.50  a.m. 
on  following  morning,  five  days  after  first  appearance  of  cerebral 
symptoms. 

Autopsy. — Body  well  nourished.     Much  purple  lividity  of  integu- 
ments, and  deep  jaundiced  hue  of  skin  and  of  every  tissue  of  body. 
No  scars  on  genitals   or  in  groins.     Three  or  four  pints  of  slightl}'' 
turbid  serum  in  peritoneum.     Considerable  fine  vascular  injection  of 
serous  covering  of  small  intestines,  and  particularly  of  that  of  duode- 
num ;  peritoneum  of  intestines  and  of  liver  also  coated  at  many  places 
with  a  thin  film  of  recent  lymph,  easily  ."separated.     Stomach  and  intes- 
tines distended  with  gas,  and  liver  completely  hidden  below  right  ribs, 
not  more  than  an  inch  of  it  being  opposed  to   thoracic  wall.     Liver 
extremely   small ;    its    largest    diameter   measuring    6^    inches,    and 
antero-post.  diameter  of  right  lobe  only  5   in.  ;  it  weighed  only   28 
ounces,    or  exactly   one  half  of  standard  weight  for  girl's  age  ;  very 
flabby,  and  outer  surface  wrinkled,  but  free  from  any  granular  or  nodular 
irreo-ularities.     The    substance    of    gland   extremely   friable,    and   of 
almost  pnlpy  consistence,  and  presented   at  some  places  a  tolerably 
uniform    rhubarb-yellow   colour,    with    scarcely    any    appearance    of 
lobules,  and  at  other  parts  a  similar  yellow  colour  interspersed  with 
red.     Under  microscope,   there  was  found   a  large   quantitj-   of  free 
oily  and  granular  matter,  with  globular  masses  of  leucin  and  bundles 
of  needles  of  tyrosin,  and  also,  more  especially  at  Avhat  corresponded 
to  centres  of  lobules,  entire  secreting  cells  of  large  size  and  loaded 
with  oil-globules  and  dark  greenish-yellow  yjigraent.     Bile-ducts  patent 
throughout,  not  dilated  ;  their  lining  membrane  presented  no  tinge  of 
bile,  although  gall-bladder  contained  about   a   teaspoon ful    of  dark- 
green  viscid  bile,  which  could  be  squeezed  out  through  cystic  duct. 
Contents  of  intestine  consisted  throughout  of  a  very  pale  yellowish 
pulp ;    mucous  membrane  of  bowels    nowhere   ulcerated.     Spleen  of 
normal  size,  rather  soft.     Both  kidneys  sligiitly  enlarged,  extremely 
soft,  and  tinged  with  bile  pigment ;  I'cnal  epithelium  contained  a  large 
quantity  of  fine  granular  matter ;  crystals  of  both  leucin  and  tyrosin 
were  detected  in  renal  tissue.     Bladder  empty  and  uterus  unimpreg- 
nated.     Much  hypostatic  congestion  of  both  lungs.     Pericardium  con- 
tained more  than  an  ounce  of  yellow  scrum  ;  heart  healthy  ;  blood  dark 
and  fluid.     Excepting  an  increased  amount  of  serosity  in  lateral  ven- 
tricles and  beneath  arachnoid,  neither  brain  nor  membranes  presented 
anything  abnormal. 


LECT.  vni.  ACUTE    ATROPHY.  2/1 

Case  CIII. — Jcmndice  from  Gall-stones,  fulloiued  Ity  Acute  Atroijhy  of  the 
Liver,  with  Puriform  Deposits. 

James  H ,  ^t.  66,  was  adm.  into  Middlesex  Hosp.  on  Oct.  11, 

1870.  As  a  tailor  he  had  led  a  sedentary  life  ;  he  had  lived  well  and 
drunk  a  good  deal  of  beer,  but  at  no  time  been  intemperate.  Except- 
ing slight  cough  and  occasional  symptoms  of  indigestion,  and  three 
attacks  of  gout  in  big  toe,  he  had  enjoyed  good  health  until  seven 
weeks  before  admission,  when  he  was  suddenly  seized  in  night  with 
violent  pain  in  epigastrium  and  right  hypochondrium,  frequent  vomit- 
ing, rigors,  and  cold  perspirations.  On  following  day  he  was  jaun- 
diced. The  jaundice  disappeared  after  a  few  days  ;  but  the  pain  and 
sickness  continued  to  recur  at  frequent  intervals,  and  a  week  before 
admission  he  had  a  severe  attack,  followed  by  jaundice,  which  persisted. 

On  admission,  jaundice  was  patient's  prominent  symptom  ;  much 
bile-pigment  in  urine,  but  none  in  faeces.  Liver  enlarged,  measuring 
6^  in.  in  right  nipple  line.  Excepting  the  jaundice,  patient's  general 
aspect  was  that  of  a  healthy  man  for  his  age.  Pulse  60  ;  skin  cool ; 
tongue  coated  ;  solid  food  was  at  once  rejected  by  vomiting  ;  bowels 
open  by  medicine.  IS'o  albumen  in  urine.  On  following  day,  Oct.  12, 
patient's  condition  was  entirely  changed.  Pyrexia  had  set  in ;  pulse  96, 
and  temperature  101'2°  Expression  heavy  and  stupid.  No  pain 
complained  of.  Oct.  14. — Tongue  dry  and  brown  down  centre. 
Jaundice  and  vomiting  persisted.  Ko  rigors  or  perspirations.  Oct. 
16. — Tongue  dry  all  over ;  much  thirst ;  bowels  not  open ;  frequent 
hiccough ;  drowsy  and  heavy,  but  did  not  wander.  Pulse  92  ;  temp. 
100'6°  ;  no  rigors  nor  perspirations.  Oct.  17. — Pulse  68  ;  temp.  97'2° 
in  morning,  and  10]  "6°  in  evening.  Urine  contained  much  bile-pigment, 
and  also  crystals  of  tyrosin  and  leucin,  but  no  albumen.  Oct.  18. — 
Pulse  84  to  120  ;  temperature  100-1°  to  103-1°.  Much  hiccough.  Urine 
passed  involuntarily.  Oct.  19. — Stupor  increased.  Urine  still  contained 
tyrosin,  but  no  albumen.  Liver  appeared  to  be  diminishing  in  size, 
and  did  not  exceed  4  in.  in  right  nipple  line.  Oct.  22. — Pulse  80  in 
the  morning,  140  in  evening ;  temp.  96-6°  in  morning,  102-2°  in 
evening.  Less  hiccough  ;  abdomen  distended  and  tympanitic. 
Still  much  jaundice,  but  motions  now  contained  bile.  All  day 
he  lay  in  a  heavy  drowsy  state,  but  in  evening  he  became  very 
restless,  tossing  about  and  throwing  off  bed-clothes.  Hands  tremu- 
lous, occasional  delirium.  Oct.  26. — Pulse  100  ;  temp.  101-2°.  Urine 
still  contained  tyrosin  and  fair  amount  of  urea,  but  no  albumen.  Oct. 
27.— Pulse  96  ;  temp.  98-4°  to  100°.  Considerable  delirium,  and  fre- 
quent attempts  last  night  to  get  out  of  bed.  Still  no  rigors  nor 
sweating.  Urine  contained  a  trace  of  albumen.  Oct.  28. — Pulse  128  • 
temp.  103-2°  Nov.  2.— Pulse  80  ;  temp.  96-8°  ;  last  night  it  was  as  low 
as  95-5°,  and  at  no  time  during  last  two  days  has  it  exceeded  98'2°. 
Patient  still  very  restless,  but  much  weaker  ;  now  almost  unconscious, 


2/2  CONTRACTIONS    OF   THE    LIVER.  lect.  vin. 

with  occasional  miTttering  delirium.  Hepatic  dulness  in  riglit  nipple 
only  3^  in.  Jaundice  decidedly  less  ;  bile  in  motions.  Urine  copious  ; 
it  contained  very  little  bile-pigment,  but  a  good  deal  of  tyrosin,  and 
about  one-twelfth  in  volume  of  albumen.  Nov.  3. — Pulse  felt  with 
difficulty ;  temp.  98'6°.  Nov.  4. — Pulse  scarcely  to  be  felt  ; 
temp.  96*6°  ;  voice  feeble,  and  could  not  speak  articulately ; 
quite  unconscious,  restless  and  moaning ;  tongue  dry  and  brown. 
Urine  scanty ;  contains  one-twelfth  in  volume  of  albumen  and  much 
leucin  and  tyrosin,  but  very  little  urea  ;  less  jaundice ;  complexion 
dusky  ;  no  purpuric  spots.  In  early  part  of  following  niglit  acute 
delirium  set  in,  followed  after  some  hours  by  great  restlessness.  At 
5  a.m.  of  Nov.  6th  he  became  quiet,  but  his  respirations  were  quick 
(48).  At  11.30  a.m.  death  occurred,  being  preceded  by  slight  convul- 
sions. 

Autopsy. — Body  thin  ;  only  faint  jaundice  of  skin  and  tissues ;  no 
purpura-spots.  No  peritonitis,  old  or  recent.  Surface  of  liver 
smooth ;  capsule  not  thickened.  Liver  large  and  heavy,  94  oz.,  but 
not  so  much  as  three  inches  apposed  to  wall  of  chest  and  abdomen,  the 
organ  being  soft  and  folded  upon  itself,  and  overlapped  to  an  unusual 
extent  by  right  lung.  On  cutting  into  liver  it  presented  numerous 
patches  of  yellow  opaque  fluid  having  all  naked-eye  characters  of  pus 
contained  in  cavities  with  well-defined  walls,  which  were  apparently 
dilated  bile-ducts.  These  cavities  varied  from  size  of  a  pea  to  that  of 
a  small  cherry.  Under  microscope  the  yellow  fluid  was  found  to  con- 
tain a  few  pus-corpuscles,  but  to  be  made  up  chiefly  of  oily  matter. 
The  hepatic  tissue  was  unusually  soft,  and  of  a  yellowish  or  rhubarb 
colour.  It  contained  many  tracts  where  it  was  impossible  to  trace  any 
outline  of  lobules,  and  where  the  liver-cells  wore  replaced  by  oil, 
granular-matter,  and  round  nuclei.  No  leucin  nor  tyrosin  could  be 
found  at  first,  but  after  liver  had  been  for  some  time  in  spirit  it  was 
found  to  contain  many  crystals  of  tyrosin.  The  gall-bladder  contained 
more  than  twenty  polyhedral  calculi^  about  the  size  of  peas.  The 
cystic  duct  was  so  dilated  that  the  little  finger  could  be  inserted  into  it. 
The  hepatic  and  common  ducts  Avere  also  much  dilated ;  the  tijD  of 
index  finger  could  be  passed  into  either  of  them.  The  duodenum  for 
three  or  four  lines  round  orifice  of  common  duct  was  ulcerated  ;  it  con- 
tained bile,  which  could  also  be  squeezed  into  it  from  the  gall-bladder. 
All  the  ducts  in  intci-ior  of  liver  were  dilated,  and  the  hepatic  duct 
contained  three  calculi  larger  than  those  in  gall-bladder,  each  being 
about  half  size  of  a  cherry.  No  gall-stones  were  found  in  bowels. 
Spleen  large  and  soft,  7f  oz.  The  kidneys  were  congested ;  each 
weighed  0^  oz. ;  both  were  marked  by  old  cicatrix-like  depressions  on 
surface,  and  there  were  several  small  cysts  in  cortex  of  the  right ;  both 
kidneys  also  contained  a  few  minute  opaque  yellow  soft  masses  of  pus  ; 
in  other  respects  they  appeared  healthy.  Heart  14  oz. ;  valves  healthy. 
Lungs  congested  posteriorly,  but  otherwise  healthy. 


LECT.  Till.  ACUTE    ATEOPHT.  2/3 

This  patient's  symptoms  left  no  doubt  tliat  his  illhess  com- 
menced with  the  passage  of  gall-stones ;  but  it  was  equally 
clear  that  there  was  some  cause  other  than  gall-stones  for 
jaundice  which  persisted  long  after  the  motions  contained  bile, 
and  VN^hich  was  accompanied  by  pyrexia  and  by  the  cerebral  and 
other  symptoms  of  the  typhoid  state. 

Jaundice  with  fever  and  cerebral  symptoms,  and  with  bile 
in  the  motions,  is  due  to  one  of  three  causes  : — 

1.  A  specific  poison,  such  as  that  of  yellow  fever,  relapsing 
fever,  or  typhus.  2.  Pysemic  abscesses  of  the  liver.  3.  Acute 
atrophy  of  the  liver.  With  regard  to  the  first  cause  there  was 
no  evidence  that  the  patient  was  suffering  from  any  of  the  acute 
specific  diseases,  so  that  the  question  to  be  decided  was  whether 
he  had  acute  atrophy  or  pyeemic  abscesses  of  the  liver.  The 
latter  view  was  favoured  by — a,  the  large  size  of  the  liver,  and 
h,  the  fact  that  gall-stones  are  known  to  cause  ulceration  of 
the  biliary  passages,  with  secondary  pysemic  inflammation  of 
the  liver.  It  was  contraindicated,  however,  by — a,  the  absence 
of  rigors  or  profuse  perspiration  throughout  the  entire  illness, 
although  both  these  symptoms  are  sometimes  absent  in  pysemia 
from  internal  causes ;  and  h,  the  fact  that  the  liver  diminished 
in  size,  instead  of  increasing,  as  the  disease  advanced.  Acute 
atrophy  of  the  liver  was  contraindicated  by — a,  the  large  size 
of  the  liver,  and  h,  by  the  comparatively  chronic  course  of  the 
malady;  bat  two  facts  were  strongly  in  favour  of  it,  viz.,  a,  the 
circumstance  that  the  liver  diminished  in  size  as  the  disease 
advanced;  and  6,  the  presence  of  leucin  and  tyrosin  and  the 
diminution  of  the  urea  in  the  urine.  The  diagnosis  arrived  at 
was  that  the  liver  had  become  enlarged  from  obstruction 
of  the  bile-ducts  by  gall-stones,  and  that  atrophy  of  the  liver 
had  supervened  on  this,  and  had  continued  after  removal  of  the 
obstruction.  Such  cases  are  referred  to  by  Trerichs  in  the 
following  passage  of  his  work  on  '  Diseases  of  the  Liver.' 

'  In  some  cases  when  obstruction  of  the  bile-duct  has  lasted 
for  several  months,  it  gives  rise  to  an  atrophy  of  the  gland, 
which  in  many  points  resembles  acute  atrophy.  The  organ 
diminishes  in  size  and  becomes  soft;  the  cells  of  the  paren- 
chyma, which  are  infiltrated  with  bile,  become  disintegrated 
into  a  finely  granular  debris,  mingled  with  oil-globules  and 
particles  of  pigment,  while  at  the  same  time  large  quantities  of 
leucin  and  tyrosin  may  be  detected.'  ^ 

'  Syd.  Soc.  Transl.  vol.  i.  p.  237. 
T 


2/4  CONTRACTIOXS    OF    THE    LIVER.  lect.  viii. 

In  the  case  now  recorded  it  is  to  be  noted  that  the  process 
of  atrophy  continued  after  the  removal  of  the  obstruction. 

The  autopsy  in  this  case,  however,  disclosed  not  only  atrophy 
of  the  hepatic  tissue,  but  puriform  collections  in  the  liver.  It 
is  true  that  these  collections  Avere  composed  mainl}^  of  oily 
matter,  yet  the  ulcerations  at  the  duodenal  orifice  of  the 
common  duct,  the  great  variations  in  the  temperature  observed 
during  life,  and  the  fact  of  a  few  minute  deposits  of  pus  being 
found  in  the  kidneys,  all  suggested  that  the  patient  was  the 
subject  of  pysemic  inflammation,  as  well  as  of  acute  atrophy  of 
the  liver. 

III.    CHRONIC    ATROPHY. 

Under  this  head  it  will  be  convenient  to  consider  several 
diseases,  which  in  their  etiology  and  anatomical  characters 
are  essentially  distinct,  but  which  often  j^resent  syznptoms  so 
similar  that  it  may  be  impossible  during  life  to  distinguish 
them.     The  diseases  I  refer  to  are  these  : — 

I.  Cirrhosis,  or  the  so-called  '  gin-drinker's  liver,'  in  which 
the  liver  becomes  reduced  in  size  in  cdnsequence  of  an  atrophy 
or  slow  destruction  of  the  secreting  tissue,  but  where  the  fibrous 
tissue  is  increased  in  amount,  so  that  the  organ  is  preter- 
naturally  dense  and  firm.  The  outer  surface  also  presents  a 
granular  or  nodulated  character,  which  has  earned  for  the 
disease  the  designation  of '  hobnailed  liver,'  and  on  section  the 
organ  presents  firm  fibrous  bands,  including  the  remains  of 
vessels  and  bile-ducts  and  surrounding  islets  of  yellow  '  secret- 
ing tissue.  The  capsule  also  is  sometimes  thickened  and 
adherent  to  surrounding  parts.  In  a  former  lecture  I  have 
pointed  out  to  you  that  the  contracted  state  is  very  often  pre- 
ceded by  considerable  enlargement  of  the  liver.  True  cirrhosis 
can  almost  invariably  be  traced  to  the  abuse  of  strong  spirits, 
and  especially  to  the  habit  of  drinking  them  neat,  and  accord- 
ingly it  is  most  common  in  those  countries  and  towns  where 
such  a  habit  prevails.     (Case  CXL). 

II.  Hypersemia  from  obstructed  circulation  in  cardiac  and 
pulmonary  diseases  causes,  in  the  first  place,  enlargement  of  the 
liver  (see  pp.  l'J3,  137)  ;  but  when  of  long  standing,  the  enlarge- 

'  This  yfllow  colour  is  due  to  the  larfre  quantity  of  yellow  pigment  contained  in 
the  secreting  cells.  It  is  from  this  character  that  the  term  cirrhosis  {Ki^fior,  yellow), 
is  derived,  and  the  application  of  the  term  to  diseases  of  other  organs,  such  as  the 
luiifjs,  or  kidneys,  which  resemble  cirrhosis  of  the  liver,  not  in  the  yellow  colour,  but 
in  the  fibroid  condensation  of  the  tissue,  is  obviously  inappropriate. 


tECT.   Vlll. 


CHEONIC    ATROPHY.  2/5 


ment  is  followed  by  an  opposite  condition  of  atroj^liy.  The 
liver  also  becomes  firm,  tenacious,  and  finely  granular,  and 
presents  an  appearance  wliicli  bas  frequently  been  mistaken 
for  cirrhosis.  The  depressions,  however,  correspond  to  the 
centre  of  the  lobules,  whereas  in  true  cirrhosis  they  are  at  the 
circumference.  The  atrophy  is  due  to  the  pressure  exerted  by 
the  distended  capillaries  of  the  hepatic  vein  on  the  surrounding- 
secreting  cells.  These  cells  disappear,  so  that  the  central 
portions  of  the  lobules  sink  down,  while  the  portions  occupied 
by  the  branches  of  the  portal  vein  project  as  fine  granulations. 
After  a  time  the  atrophy  extends  to  the  circumference  of  the 
large  branches  of  the  hepatic  vein,  so  as  to  cause  extensive 
depressions,  and  new  connective  tissue  is  developed  around  the 
vessels,  imparting  to  the  organ  a  greater  degree  of  firmness, 
and  more  or  less  obstructing  or  obliterating  the  minute  branches 
of  the  portal  vein.  This  condition  of  liver  is  not  uncommon  in 
cases  of  valvular  disease  of  the  heart  of  long  standing.     (Case 

CXI  v.). 

III.  An  atrophy  of  the  liver  where  the  organ  also  presents 
a  granular  or  nodulated  outer  surface  resembling  what  is  seen 
in  true  cirrhosis,  but  where  the  fibrous  tissue  is  not  increased, 
so  that  the  liver  instead  of  being  preternaturally  dense  is  softer 
than  in  health.  In  some,  if  not  all,  of  these  cases  there  is  no 
histor}^  of  spirit-drinking  (see  Case  CXII.) 

IV.  An  atrophy  of  the  liver  resulting  from  frequent  attacks 
of  peri-hepatitis  or  inflammation  of  the  capsule.  In  these 
cases  the  capsule  becomes  greatly  thickened  and  is  often  con- 
nected to  surrounding  parts  by  firm  bands  of  adhesion.  Fibrous 
bands  also  pass  from  the  thickened  capsule  into  the  interior  of 
the  liver,  which  on  section  often  presents  a  dense,  smooth,  uni- 
form surface,  with  the  outline  of  the  lobules  more  or  less 
obliterated.  This  condition  of  liver  has  been  described  by  some 
writers  under  the  name  of  '  simple  induration,'  and  is  most 
common  in  patients  who  have  suffered  from  constitutional 
syphilis  ;  it  is  also  met  with  occasionally  in  cases  of  valvular 
disease  of  the  heart  of  long  standing,  in  ague,  and  in  connec- 
tion with  inflammation  of  the  right  pleura,  ulceration  of  the 
mucous  membrane  of  the  stomach,  and  various  diseases  of  the 
secreting  tissue  of  the  liver  itself.  In  these  cases  inflamma- 
tion is  propagated  to  the  capsule  of  the  liver  through  the 
diaphragm,  along  the  coronary  ligament,  or  from  the  subjacent 
glandular  tissue.     When  the  disease  has   a  syphilitic  origin, 

T  2 


2/6  CONTRACTIONS    OF    THE    LIVER.  lect.  via. 

tlie  surface  of  tlie  contracted  liver  is  often  marked  by  cicatrix- 
like  depressions  or  deep  fissures,  giving  tlie  organ  a  lobular 
character,  and  gummatous  tumours  are  found  in  tlie  interior ; 
under  other  circumstances,  the  outer  surface  is  smooth,  and  it 
never  presents  the  hobnailed  character  of  true  cirrhosis.  Now 
and  then  the  fibroid  tissue  developed  in  the  portal  fissure  from 
the  products  of  inflammation  produces  constrictions  of  the  bile- 
duct  or  portal  vein. 

V.  In  the  next  place  there  is  the  '  chronic  atroph}^ '  of 
Frerichs,  or  the  '  red  atrophy '  of  Eokitansky.  Here  there  is  no 
nodulation  or  granulation  of  the  outer  surface,  and  not  neces- 
sarily any  thickening  or  adhesions  of  the  capsule,  but  the 
secreting  tissue  contains  a  large  quantity  of  blood,  and  j)resents 
on  section  a  dark-brown  or  bluish-red  colour,  a  rather  firm 
consistence,  and  a  homogeneous  appearance  with  little  or  no 
indication  of  a  division  into  lobules.  The  secreting  cells  are 
often  smaller  tlian  natural,  and  loaded  with  brown  pigment- 
granules.  The  atrophy  of  the  organ  is  general,  although  its 
thickness  often  preponderates  over  the  other  dimensions,  and 
occasionally  there  is  a  broad  rim  of  atrophied  hepatic  tissue 
round  the  edge.  The  entire  organ  has  been  known  to  weigh 
only  24  oz.  But  the  most  important  anatomical  character 
is  the  destruction  of  the  ramifications  of  the  portal  vein,  the 
branches  of  which  terminate  in  blind  club-shaped  extremities, 
so  that  the  organ  cannot  be  minutely  injected  from  the  portal 
vein.  This  form  of  atrophy  is  occasionally  seen  in  connection 
with  simple  and  cancerous  ulcerations  of  the  stomach  and  in- 
testines, or  in  the  bodies  of  persons  who  have  suffered  long  or 
often  from  intermittent  or  remittent  fevers  :  in  the  latter  case 
there  is  often  a  deposit  of  black  pigment  in  the  minute  vessels 
of  the  liver. 

In  all  of  these  diseases  there  is  one  anatomical  character  in 
common,  viz. — a  destruction  to  a  greater  or  less  extent  of  the 
minute  branches  of  the  portal  vein  in  the  interior  of  the  liver. 
To  this  cause  must  be  attributed  the  clinical  sjnnptoms  in  which 
during  life  they  so  closely  resemble  one  another.  The  prominent 
symptoms  in  all  of  them  are  those  of  obstructed  portal  circula- 
tion. It  will  bo  convenient  therefore  to  describe  to  you  in  the 
first  place  the  typical  symptoms  in  a  case  of  true  cirrhosis,  and 
afterwards  to  mention  those  circumstances  which  may  serve  to 
distinguish  from  it  the  other  forms  of  chronic  atrophy. 

I.  First  then  let  us  consider  the  clinical  characters  of  true 


LECT.  VIII.  CHRONIC    ATROPHY.  2/7 

cirrliosis.  This  is  a  clironic  disease  ;  its  history  usually  extends 
over  several  years,  and  may  be  conveniently  divided  into  two 
stages,  that  which  precedes,  and  that  which  follows,  the  destruc- 
tion of  the  minute  branches  of  the  portal  vein. 

A.  First  Stage. — The  disease  at  its  outset  is  usually  in- 
sidious. 

1.  The  early  symptoms  are  those  of  alcoholic  dyspepsia, 
such  as  retching  in  the  morning  and  a  feeling  of  sinking  in- 
ducing a  craving  for  alcohol,  loss  of  appetite  for  solid  food, 
furred  tongue,  bitter  taste,  flatulence  and  pain  after  food, 
attacks  of  diarrhcea  alternating  with  constipation,  hsemorrhoids, 
urine  dark  and  frequently  turbid  from  lithates  and  sometimes 
containing  bile-pigment,  and  languor  with  depression  of  spirits. 
The  intensity  of  these  symptoms  varies  at  different  times,  and 
at  intervals  the  patient  may  seem  perfectly  well. 

2.  After  a  time  the  patient  becomes  thin  and  sallow,  and 
venous  stigmata  are  developed  on  the  cheeks.  A  dull  pain- 
with  slight  tenderness  in  the  right  hypochondrium  is  often 
present,  and  pain  is  sometimes  referred  to  the  right  shoulder. 

3.  Tour  attention  has  been  already  called  to  the  circum- 
stance that  with  these  symptoms  the  liver  is  often  considerably 
enlarged  (see  p.  139). 

4.  The  disease  also  commences  now  and  then  in  a  more 
acute  manner,  with  febrile  symptoms,  pain  in  the  hepatic 
region,  vomiting,  jaundice,  and  diarrhoea.  But  in  these  cases 
there  has  probabl}'-  been  chronic  mischief  previously,  and  the 
acute  symptoms  have  followed  some  imprudence  in  diet  or  un- 
usual excess  in  stimulants,  or  a  chill.     (See  Appendix.) 

5.  There  is  a  history  of  an  immoderate  use  of  wine  or 
spirits,  and  particularly  of  the  habit  known  as  '  nipping.'  The 
patient  rarely  takes  sufficient  stimulants  to  affect  the  brain, 
and  is  often  indignant  at  the  suggestion  that  he  has  exceeded 
a  moderate  allowance,  but  you  will  remember  what  I  told  you 
in  a  former  lecture  (p.  141),  that  what  is  a  moderate  allowance 
for  one  person  may  excite  serious  disease  in  another. 

B.  Second  Stage. — The  symptoms  in  this  stage  are  usually 
well  marked,  and  are  mainly  due  to  the  obstructed  portal 
circulation. 

1.  The  area  of  hepatic  dulness  is  diminished  (see  fig.  27). 
It  may  be  reduced  to  one-half  of  the  normal  standard,  or  even 
to  less.  The  atrophy  is  usually  greatest  in  the  left  lobe,  the 
dulness  of  which  may  entirely  disappear.     The  dulness  also  of 


278 


CONTRACTIO]!ifR    OF    THE    LIVER. 


LECT.    Till. 


the  right  lobe  may  be  reduced  to  a  greater  extent  than  would 
be  accounted  for  by  the  actual  decrease  of  the  liver,  owing  to 
its  lower  edge  being  tilted  up  by  the  pressure  of  fluid  in  the 
peritoneum,  or  of  gas  in  the  bowels,  which  at  the  same  time 
increases  the  antero-posterior  diameter  of  the  abdomen,  and 
diminishes  the  extent  of  liver  which  is  in  apposition  Avith  the 
abdominal  parietes.  It  must  not  be  forgotten,  however,  that 
the  interstitial  hepatitis  which  leads  to  cirrhotic  contraction 
may  induce  all  the  signs  of  portal  obstruction,  although  the 
liver  is  considerably  enlarged  (see  pp.  139,  142). 

2.    The    nodulated   or   hobnailed    character   of   the   outer 


Fig.   27.     ShoAvs   the  hepatic  and  ascitic  duliie.ss  in  cirrhosis.     Tliomas  B , 

Case  CIV.  (p.  291). 

a.  Dulness  of  contracted  liver,    b.  Fluid  in  peritoneum  causing  bulging  of  flanks,    c.  Tympanitic 
bowels.    (/.  Enlarged  spleen,    e.  Heart. 

surface  of  the  liver  may  sometimes  be  felt  through  the  abdo- 
minal parietes,  and  lend  assistance  to  the  diagnosis.  More 
commonly,  by  the  time  that  the  irregularity  of  the  surface  is 
sufficient  for  this  purpose,  the  organ  is  so  small  that  its  lower 
margin  is  concealed  by  the  ribs,  or  by  fluid  in  the  peritoneum. 
In  those  cases  where  the  liver  is  enlarged  (see  pp.  32,  139)  its 
outer  surface  may  be  marked  by  large  nodules,  separated  by 
deep  Assures,  and  this  nodulated  character  may  be  easily  dis- 
tinguished through  the  abdominal  parietes,  and,  as  I  have 
alread}'  shown  you  (p.  213),  may  simulate  cancer.  In  regard 
to  diagnosis  also,  it  is  necessary  to  keep  in  view  the  possibility 


LECT.  vni.  CHEOKIC    ATEOPHT.  2/9 

of  a  nodulated  character  of  the  liver  being  congenital,  or  the 
result  of  obliteration  of  large  branches  of  the  portal  vein.  In 
the  latter  case,  the  surface  of  the  liver  presents  deep  fissures, 
caused  by  the  atrophy  of  the  glandular  tissue,  which  had  for- 
merly been  supplied  with  blood  by  the  obliterated  vessel. 

3.  Ascites.     A  dropsical  collection  of  fluid  in  the  perito- 
neum, without  any  pain  or  tenderness  of  the  abdomen,  is  one 
of  the  most  common  results  of  portal  obstruction,  and  is  met 
with  oftener  in  cirrhosis  than  in  any  other  disease  of  the  liver. 
The  fluid  in  the  peritoneum  is  a  clear  yellow  serum,  having  a 
specific    gravity   of    from    1012    to    1016,    containing  a   large 
quantity  of  albumen,  but  no  blood  or  inflammatory  products. 
In  consequence  of  the  distension  of  the   veins  which  return 
the  blood    from    the  peritoneum,  the  serous    portion    of    the 
blood    transudes    through  the   walls    of   the  vessels  into    the 
peritoneal  cavity.     When    once    it   appears,    it   persists    and 
gradually  increases.     When  the  amount  of  fluid  is  large,  it  may 
compress  the  inferior  vena  cava  and  the  iliac  veins,  and  thus 
produce  secondary  oedema  of  the  legs  :  but  it  is  a  peculiarity  of 
dropsy  from  uncomplicated  portal  obstruction,  that  the  ascites 
j)recedes  and  preponderates  over   dropsy  elsewhere.     A  great 
amount  of  as.cites  may  also  interfere  with  the  action  of  the 
diaphragm  and  cause  much  embarrassment  of  the  breathing, 
but  it  is   distinguished  from  the  ascites  produced  by  cardiac 
disease,  by  the  fact  that  the  dyspnoea  follows  and  never  pre- 
cedes the  ascites. 

Frerichs  noted  ascites  in  only  twenty-four  out  of  thirty-six 
cases  of  cirrhosis :  patients  with  cirrhosis  may  no  doubt  die  iii 
various  ways  before  there  is  any  ascites,  but  in  the  advanced 
stages  of  the  disease  ascites  is  rarely  absent. 

4.  Enlargement  of  the  spleen  causing  an  increased  area  of 
splenic  dulness  is  another  common  consequence  of  the  me- 
chanical obstruction  to  the  circulation  through  the  liver, 
although,  on  the  whole,  it  is  less  common  than  might  at  first  be 
imagined.  It  is  present  in  about  one-half  of  the  cases.  Its 
absence  is  sometimes  attributable  to  fibrous  thickening  or 
calcification  of  the  capsule  interfering  with  the  dilatation  of 
its  contained  vessels,  and  at  other  times  to  an  excessive  drain 
from  the  gastro-intestinal  raucous  membrane,  caused  by  diar- 
rhoea or  hsemorrhage. 

5.  Enlargement  of  the  superficial  veins  of  the    abdomen, 
especially  on  the  right  side  and  between  the  sternum  and  the 


280  CONTRACTIONS    OF    THE    LIVER.  lect.  tiii, 

umbilicus,  is  anotlier  result  of  the  impediment  to  the  current  of 
portal  blood,  usually  observed  in  advanced  cirrhosis.  When 
the  portal  vein  is  obstructed,  in  consequence  of  the  anastomoses 
between  the  inferior  mesenteric  and  the  hypogastric  veins 
through  the  inferior  hsemorrhoidal,  the  blood  is  returned  in 
part  to  the  heart  by  the  hypogastric  veins.  It  must  be  borne 
in  mind,  however,  that  a  similar  enlargement  may  be  noticed  in 
extreme  and  protracted  ascites  from  an}'  cause,  owing  to  the  pres- 
sure of  the  fluid  on  the  vena  cava  inferior.  In  this  case,  however, 
there  is  usually  also  varix  of  the  veins  of  the  lower  extremities. 

6.  Hsemorrhoids  not  uncommonly  result  from  the  same 
cause  as  the  enlargement  of  the  abdominal  veins,  and  often 
precede  the  other  signs  of  portal  obstruction.  Haemorrhoids, 
indeed,  in  a  large  number  of  cases,  are  due  to  obstructed  portal 
circulation,  and  you  will  do  Avell  to  remember  that  neglect  of 
this  fact  has  too  often  led  to  serious,  and  even  fatal,  results. 
The  blood  from  the  rectum  must  pass  through  the  liver,  and 
the  occasional  discharge  of  blood  from  piles  acts  as  a  sort  of 
safety-valve  for  relieving  the  overfilled  radicles  of  the  portal 
vein.  Remove  this  safety-valve  by  operating  on  the  piles,  and 
there  is  a  risk  of  increased  mischief  in  the  liver,  ascites,  or 
hsematemesis,  ensuing.' 

7.  Haemorrhages  I'rom  the  mucous  membrane  of  the  stomach 
and  bowels  occasionally  take  place  and  are  sometimes  profuse 
and  fatal,  even  before  the  occurrence  of  ascites.  In  some  cases 
they  are  followed  for  a  time  by  great  relief.  The  minute  vessels 
of  the  mucous  membrane  rupture,  owing  to  their  extreme  dis- 
tension with  blood  and  to  the  collateral  circulation  not  being 
sufficiently  developed.  Epistaxis,  purpuric  spots  and  blotches 
on  the  skin,  bleeding  from  the  gums,  ecchymoses  about  the 
punctures  of  the  lancets  in  cupping,  and  other  haemorrhages 
which  are  obviously  independent  of  a  mechanical  cause  and  are 
probably  the  result  of  some  altered  condition  of  the  blood,  are 
not  uncommon  in  the  advanced  stages  of  cirrhosis,  and  are 
always  of  bad  omen. 

8.  Catarrh  of  the  stomach  and  bowels  also  frequently  occurs 

'  'Wheqlmffled  by  unto-wiirtl  circnmstanccs  the  bowels  plague  nic  too,  and  dis- 
charfres  of  blood  relieve  the  headache,  and  are  as  safety-valves  to  the  system.  I  was 
nearly  persuaded  to  allow  Mr.  Syme  to  operate  on  nio  when  last  in  England,  but  an 
old  friend  told  me  that  his  own  father  had  been  operated  on  by  the  famous  John 
Hunter,  and  died  in  consequence  at  the  early  age  of  forty.  His  advice  saved  me,  for 
this  complaint  has  been  my  safety-valve.'  —  The  Last  JournuU  of  David  Luivgstone, 
1874,  vol.  iii.  p.  124. 


LECT.  Till.  CHEONIC    ATROPHY.  28 1 

in  the  course  of  cirrhosis,  the  congested  mucous  membrane 
being  excited  to  inflammation  by  causes  -which  would  other- 
wise be  inert.  Their  occurrence  is  marked  by  abdominal 
tenderness,  pain  and  vomiting  after  food,  and  obstinate 
diarrhoea,  with  more  or  less  fever.  In  such  cases  we  often 
find  after  death  the  typical  anatomical  characters  of  catarrhal 
inflammation  with  hsemorrhagic  erosions  in  the  mucous  mem- 
brane of  the  stomach,  appearances  which  by  the  inexperienced 
are  not  unfrequently  believed  to  result  from  some  irritant 
poison.  Like  hssmorrhage,  attacks  of  diarrhoea  in  the  course 
of  cirrhosis  are  often  salutary  and  ought  not  to  be  hastily 
checked.  More  than  once  I  have  known  ascites  induced  by 
the  injudicious  use  of  astringents.  Where  waxy  degeneration 
coexists  with  cirrhosis,  thei-e  may  be  profuse  and  obstinate  diar- 
rhoea from  waxy  disease  of  the  bowels. 

9.  Pain  in  the  region  of  the  liver  is  not  a  prominent 
symptom  of  true  cirrhosis.  In  the  early  stage  there  is  some- 
times a  dull  heavy  pain  with  some  tenderness  in  the  right 
hypochondrium  arising  from  congestion,  and  throughout  the 
disease  there  may  be  acute  pain  and  tenderness  of  a  temporary 
nature  resulting  from  intercurrent  attacks  of  peri-hepatitis, 
but  in  the  intervals  of  these  attacks  there  is  but  little  pain  or 
tenderness  in  the  region  of  the  liver. 

10.  Decided  jaundice  is  a  rare,  and  when  persistent  a  bad, 
symptom  in  cirrhosis.  In  the  early  stage  there  may  be 
jaundice  from  congestion ;  but  when  jaundice  shows  itself 
subsequently  it  is  usually  the  result  of  some  complication,  such 
as  catarrh  of  the  ducts,  or  enlarged  giands  in  the  fissure  of  the 
liver  compressing  the  bile-duct.  Persistent  jaundice  may  also 
show  itself  in  the  advanced  stages  of  the  malady,  and  be  asso- 
ciated with  haemorrhages,  dry  brown  tongue,  oflensive  breath, 
and  restlessness.  These  symptoms  are  always  ominous,  even 
where  there  is  no  ascites ;  they  are  often  followed  by  cerebral 
symptoms.  Dr.  Fagge,  however,  has  observed  a  case  of  cirrhosis 
with  persistent  jaundice  for  seven  years,  in  which  the  patient 
died  at  last  of  hsematem.esis.^  (See  also  Case  C.  p.  249.) 

But  although  decided  jaundice  is  rarely  met  with  in  cirrhosis, 
there  are  few  patients  who  do  not  throughout  the  disease 
present  a  persistent  sallowness  of  the  complexion,  with  a  dark 
areola  round  the  eyes,  and  yet  the  motions  are  coloured  by  bile 
and  the  urine  contains  little  or  no  bile-pigment.  Care  must 
'  Guy's  Hosp.  Eep.  1875,  vol.  xx. 


282  CONTRACTIONS    OF    THE    LIVER.  lect.  vm. 

be  taken  not  to  confound  with  this  sallowness  the  bronzed 
appearance  of  the  face  from  exposure  to  the  sun  in  hot  climates, 
or  the  waxen  complexion  of  anasmia.  The  combination  of  this 
sallowness  with  sunken  features  and  venous  stigmata  on  the 
cheeks  constitutes  the  characteristic  phj^siognomy  of  cirrhosis. 

11.  The  digestive  functions  are  sometimes  in  a  tolerably 
normal  condition,  but  more  commonly  there  is  loss  of  appetite, 
with  flatulence  and  constipation,  morning  sickness,  or  the 
symptoms  of  gastro- enteritis  already  referred  to. 

12.  The  urine  is  almost  invariably  very  scanty,  high-coloured 
and  acid,  and  deposits  large  quantities  of  pink,  dark  red,  or 
brownish  urates.  Even  when  there  is  no  jaundice,  it  always 
contains  much  abnormal  pigment,  closely  allied  in  composition 
to  bile-pigment.  These  characters  are  so  constant  that  the 
secretion  of  pale  urine,  remaining  clear  after  cooling,  would 
be  a  strong  argument  against  ascites  in  any  case  being  due  to 
hepatic  disease.  Albuminuria  is  sometimes  present,  owing  to 
concurrent  Bright's  disease  of  the  kidneys;  but  you  must  re- 
member that  a  large  quantity  of  fluid  in  the  peritoneum  may 
lead  to  the  appearance  of  albumen  in  the  urine  indeijendently 
of  any  disease  of  the  kidneys,  the  albumen  disappearing  on  the 
removal  of  the  pressure  on  the  renal  veins  by  paracentesis. 

13.  Cerebral  symptoms,  such  as  drowsiness,  delirium,  coma, 
and  convulsions,  frequently  supervene  in  the  advanced  stage  of 
cirrhosis.  They  are  often  associated  with  jaundice  and  ha3mor- 
rhages,  and  they  are  a  contraindication  to  paracentesis,  as 
they  are  usually  aggravated  b}^  a  withdrawal  of  the  fluid. 

14.  In  all  cases  the  advance  of  the  disease  is  marked  by 
progressive  emaciation  and  debility.  In  consequence  of  the 
obstruction  of  the  portal  vein,  the  intestinal  absorption  of  nutri- 
tive material  is  diminished  and  then  suspended,  while  the  blood- 
forming  functions  of  the  liver  and  spleen  are  more  or  less 
impaired.  In  many  cases  the  patient  dies  by  exhaustion,  the 
intellectual  faculties  remaining  clear  to  the  last.  At  other 
times  death  is  due  to  pneumonia,  oedema  of  the  lungs,  or  acute 
peritonitis,  or  is  preceded  by  jaundice  and  the  symptoms  of 
general  blood-poisoning  already  mentioned. 

15.  The  diagnosis  of  true  cirrhosis  will  be  assisted  by  re- 
membering the  circumstances  under  which  it  occurs  : — 

a.  Age.  Cirrhosis  is  chiefly  met  with  in  adults  between 
the  ages  of  35  and  60.  It  is  extremely  rare  under  the  age  of  25, 
but  it  has  been  met  with  even  in  young  children ;  and  Case 
CXI.  is  an  example  of  the  disease  in  a  child  aged  9. 


LECT.  vni.  CHRONIC    ATEOPHT.  283 

h.  Sex.  It  is  usually  said  to  be  more  common  in  males 
than  in  females,  butmj  experience  in  London  leads  me  to  think 
that  there  is  not  much  difference  in  this  respect. 

c.  Habits.  In  almost  all  cases  there  is  a  previous  history  of 
spirit-drinking,  and  especially  a  habit  of  taking  spirits  or  strong 
wine  in  an  undiluted  form  and  on  an  empty  stomach.  It  is 
very  rare  indeed  that  true  cirrhosis  results  from  any  other  cause, 
for  although  it  occurs  occasionally  in  young  children  ^  (and  even, 
it  is  said,  in  some  of  the  lower  animals,  such  as  cattle  and  pigs) 
it  is  possible  that  the  disease  in  many  of  these  cases  is  one  of 
the  other  forms  of  chronic  atrophy  to  which  I  have  called 
your  attention.  In  young  children  the  disease  is  sometimes 
traceable  to  inherited  syphilis,  while  Case  CXI.  shows  that  the 
apparent  exceptions  may  support  the  rule,  and. that  even  in 
early  life  true  cirrhosis  may  result  from  the  abuse  of  alcohol. 

d.  Occupation.  From  what  has  been  stated  it  is  not  sur- 
prising that  the  disease  is  particularly  prevalent  among  pub- 
licans and  sailors.  Still  the  statement  recently  put  forward  on 
high  authority  that  the  disease  is  rare  among  the  upper  classes 
in  society  is  quite  contrary  to  my  experience. 

e.  Gout.  Cirrhosis  is  very  often  found  in  connection  with 
gout.  The  condition  of  liver  which  developes  gout  renders  it 
liable  to  suffer  from  alcohol,  even  in  small  quantity. 

The  clinical  characters  of  the  other  forms  of  chronic  atrophy 
are  similar  to  those  of  true  cirrhosis  as  above  described,  but  I 
may  now  mention  to  you  the  circumstances  which  during  life  may 
often  enable  you  to  distinguish  them,  although  their  distinction 
will  not  materially  influence  either  prognosis  or  treatment. 

II.  The  contraction  which  results  from  mechanical  obstruc- 
tion of  the  circulation  differs  from  true  cirrhosis  in  the  follow- 
ing respects : — 

1.  There  are  the  j)revious  history  and  the  existing  physical 
signs  of  serious  disease  of  the  heart  or  lungs. 

2.  Dyspnoea  precedes  the  ascites. 

3.  Although  the  ascites  may  preponderate  over  the  signs  of 
dropsy  elsewhere,  it  is  preceded  by  oedema  of  the  legs,  which 
persists.     (See  Case  LV.  p.  146.) 

4.  The  existence  of  true  cirrhosis  will  be  rendered  still  more 
improbable  if  there  be  an  absence  of  any  history  of  spirit- 
drinking,  or  of  alcoholic  dyspepsia. 

'  Sfe  Appendix;  also  Frericbs,  op.  cit.  vol.  ii.  p.  60;  Dr.  Griffiths,  Path.  Traus. 
vol.  xxvii.  186. 


284  CONTRACTIONS    OF    THE    LIVER.  lect.  vni. 

III.  The  atrophy  of  the  liver  in  which  the  organ  presents 
a  nodulated  outer  surface  like  that  of  true  cirrhosis,  but  which 
has  no  increase  of  the  fibrous  tissue,  and  in  consequence  has 
its  tissue  either  of  natural  consistence  or  softened  instead  of 
being  preternaturally  dense,  cannot  be  distinguished  from  true 
cirrhosis  by  any  clinical  characters  with  which  I  am  acquainted. 
In  Case  CXII.  which  was  an  example  of  this  form  of  disease, 
there  was  no  history  of  spirit-drinking,  so  that  possibly  this 
negative  character  may  be  of  some  use  in  diagnosis. 

IV.  What  is  called  simple  induration  of  the  liver,  which 
results  from  repeated  attacks  of  peri-hepatitis,  differs  from  true 
cirrhosis  in  the  following  particulars. 

1.  When  the  edge  of  the  liver  can  be  felt,  it  is  usually 
smooth  and  hard,  but  an  exception  must  be  made  with  regard 
to  those  cases  which  have  a  syphilitic  origin,  and  where,  as 
already  stated,  the  surface  of  the  liver  may  be  marked  by  j)ro- 
jecting  nodules  separated  by  deep  fissures. 

2.  Pain  and  tenderness  in  the  region  of  the  liver  are 
greater  and  more  constant  than  in  true  cirrhosis. 

3.  The  venous  stigmata  on  the  cheeks  and  the  morning 
sickness  of  alcoholic  dyspepsia  are  often  absent. 

4.  The  circumstances  under  which  simple  induration  is  known 
to  occur  are  important  in  the  diagnosis.     Thus  there  is  : — 

a.  A  clear  history  of  constitutional  syphilis,  or 
h.  A  previous  history  of  local  or  general  j)eritonitis,  of  ulcera- 
tion of  the  stomach,  or  of  inflammation  of  the  right  pleura. 

c.  An  absence  of  any  history  of  spirit -drinking. 

d.  Occasionally  simple  induration  is  met  with  in  cases  of 
valvulcir  disease  of  the  heart,  in  conjunction  with  the  second 
form  of  chronic  atrophy  already  referred  to. 

V.  Clinically  it  will  always  be  difficult,  and  ofttimes  impos- 
sible, to  distinguish  '  red  atrophy'  (see  p.  270)  from  cirrhosis  or 
simple  induration.  As  in  these  affections,  the  disease  runs  a 
chronic  course,  there  is  a  great  diminution  in  the  area  of 
hepatic  dulness,  and  there  are  the  symptoms  of  portal  obstruc- 
tion, viz.  ascites,  enlarged  spleen,  &c.  Severe  diarrhoea  is 
common,  but  there  is  rarely  any  jaundice.  The  surface  of  the 
liver,  when  it  can  be  felt,  differs  from  that  of  cirrhosis  in  being 
smooth,  but  the  chief  indications  of  its  existence  are  the  cir- 
cumstances which  precede  the  syn)ptoms  of  portal  obstruction. 

a.  There  is  no  history  of  spirit-drinking. 

h.  There  is  no  dyspnoea  or  valvular  disease  of  the  heart. 


LECT.  VIII.  CHRONIC   ATEOPHT.  285 

c.  Tliere  is  not  necessarily  any  history  of  attacks  of  peri- 
hepatitis ;  but, 

d.  In  many  cases  there  is  an  antecedent  history  of  ague  or 
malarious  remittent  fever. 

e.  In  others  there  has  been  a  history  of  dysenteric  or  other 
ulceration  of  the  intestinal  canal. 

Treatment  of  Girrliosis. 
A.  If  from  the  presence  of  the  symptoms  which  I  have  de- 
scribed to  you,  there  is  reason  to  suspect  the  existence  of  in- 
cijnent  cirrhosis,  the  indications  for  treatment  will  be  similar  to 
those  which  I  have  already  laid  down  under  the  head  of  conges- 
tion of  the  liver.  I  must  refer  you  for  details  to  the  remarks 
which  I  made  on  that  subject,  and  at  present  I  shall  merely 
mention  a  few  general  principles  for  your  guidance. 

1.  The  first  and  main  thing  to  be  done  is  to  put  a  stop  to 
the  patient's  drinking  habits.  Unfortunately  it  is  often  very 
difficult  to  effect  this.  The  patient  may  promise  obedience  to 
rules,  but  his  cravings  for  stimulants  are  irresistible.  If  alcohol 
be  permitted  at  all,  the  allowance  ought  to  be  restricted  to  a 
pint  of  hock  or  claret  in  the  24  hours,  and  even  these  wines 
are  better  diluted  in  soda  or  seltzer  water.  But  half-measures 
rarely  succeed,-  and  total  abstinence  is  more  often  successful. 
The  popular  prejudice  against  suddenly  cutting  off  an  immo- 
derate quantity  of  stimulants  is,  so  far  as  my  experience  goes, 
founded  on  error,  unless  there  be  fatty  heart,  and  the  patient's 
craving  for  stimulants  will  often  be  allayed  by  some  bitter  in- 
fusion in  combination  with  ammonia  and  ginger. 

2.  Attention  to  the  diet  is  also  of  importance.  This  ought 
to  consist  of  such  articles  as  milk,  eggs,  farinaceous  substances, 
and  plainly  cooked  white  fish,  poultry,  game,  and  meat.  All 
rich,  sweet,  and  greasy  dishes,  as  well  as  hot  spices  and  "indi- 
gestible food  of  every  sort,  ought  to  be  strictly  interdicted. 

3.  Regular  exercise  in  the  open  air  ought  always  to  be  enjoined. 

4.  The  bowels  ought  to  be  kept  regularly  and  freely  acting 
by  saline  purgatives,  such  as  the  sulphates  of  magnesia,  soda, 
or  potash,  the  bitartrate  of  potash,  Carlsbad  or  Cheltenham 
salts,  or  the  mineral  waters  of  Friedrichshall  or  Piillna.  These 
remedies  may  be  given  daily  for  two  or  three  weeks  at  a  time, 
and  they  act  best  when  taken  warm  on  first  rising  in  the 
morning.  Their  action  is  often  assisted  by  occasional  doses  of 
calomel,  blue  pill,  or  podophyllin,  with  colocynth  or  rhubarb. 


286  CONTRACTIONS    OF    THE    LIVER.  lect.  viii. 

5.  When  the  liver  is  enlarged,  advantage  is  often  derived 
from  a  course  of  iodide  or  of  bromide  of  potassium,  or  of  chloride 
of  ammonium  (p.  136)  or  of  mercury,  while  at  the  same  time 
iodine  or  iodide  of  mercury  ointment  are  rubbed  into  the  right 
hypochondrium.  Marked  results  often  follow  the  internal  ad- 
ministration of  the  green  iodide  of  mercur}^  in  doses  of  a  grain 
or  half  a  grain  three  times  daily  If  these  remedies  fail  in  re- 
ducing theliver,  the  mineral  acids  and  bitter  tonics,  and  the 
nitro-muriatic  acid  bath  (see  p.  137)  may  receive  a  trial. 

B.  In  the  second  stage  of  the  malady  no  treatment  can 
restore  the  portion  of  liver  which  has  been  destroyed,  or  remove 
the  obstruction  to  the  portal  circulation.  All  that  can  be 
done  is  to  counteract  the  effects  of  the  disease,  to  relieve  the 
engorgement  of  the  radicles  of  the  portal  vein,  and  support  the 
patient's  strength  by  appropriate  means,  with  the  hope  that  the 
progress  of  the  morbid  process  may  be  stayed,  and  that  in  time 
a  collateral  circulation  will  be  established,  by  which  the  portal 
blood  will  reach  the  right  side  of  the  heart. ^ 

1.  You  must  be  still  guided  by  the  same  rules  of  treatment 
as  in  the  early  stage  with  regard  to  alcohol,  diet,  purgatives, 
&c.  You  must  beware  of  checking  spontaneous  attacks  of 
diarrhoea,  unless  it  be  excessive. 

2.  Tonics,  such  as  nitro-muriatic  acid,  gentian,  nux  vomica, 
strychnia,  or  cascarilla,  may  be  given  from  time  to  time,  to 
improve  the  appetite,  digestion,  and  general  strength. 

3.  Ascites  will  often  call  for  treatment.  The  remedies  most 
useful  for  this  purpose  are  : — 

a.  Purgatives,  and  those  ought  to  be  selected  which  have 
most  power  in  increasing  the  Avatery  exhalation  from  the 
mucous  membrane  of  the  bowels,  such  as  the  salines  and 
mineral  waters  already  referred  to,  the  compound  jaly  p  powder, 

'  When  the  portal  vein  is  obstructed,  a  collateral  circulation  may  be  established 
by  four  different  channels,  viz. : — 

1.  The  blood  in  the  inferior  mesenteric  veins  may  be  carried  by  the  inferior 
haemorrhoidal  to  the  hypogastric  veins,  and  so  returned  to  the  heart. 

2.  By  the  cnlarirement  of  certain  branches  of  the  portal  vein  ■which  pass  between 
the  folds  of  the  falciform  ligament  from  the  liver  to  the  abdominal  parictes,  and 
there  anastomose  with  the  epigastric  and  internal  mammary  veins. 

3.  By  the  enlargement  of  twigs  of  the  portal  vein  and  of  the  veins  in  the  capsule 
of  the  liver  which  open  into  the  diaphragmatic  and  oesophageal  veins. 

4.  By  newly  formed  vessels  in  the  adhesions  between  the  liver  and  the  diaphragm 
and  abdominal  parictes.  In  advanced  cirrlmsis  it  is  not  uncommon  to  see  a  large 
vein  emerge  abruptly  just  below  the  right  false  ribs,  and  pass  up  in  a  varicose  condi- 
tion over  the  chest. 


LECT.  vin.  CHEONIC    ATROPHY.  28/ 

and  gamboge.  An  excellent  purgative  is  an  electuary  com- 
posed of  compound  jalap  powder  and  confection  of  senna. 
These  purgatives  ought  alwaj'S  to  be  given  in  the  morning 
before  food,  so  as  not  to  sweep  away  the  food  which  has  been 
digested  but  not  assimilated.  Drastic  purgatives,  such  as 
elaterium  and  croton  oil,  must  be  given  with  some  caution,  for 
obstinate  enteritis  is  one  of  the  natural  results  of  the  disease, 
and  sometimes  causes  death  by  exhaustion. 

h.  Diuretics  are  commonly  prescribed  in  conjunction  with 
purgatives,  and  different  combinations  of  them  may  be  tried. 
You  may  give  the  acetate  or  bitartrate  of  potash,  or  the  iodide 
of  potassium,  or  the  chloride  of  ammonium,  or  the  benzoate 
of  ammonia,  in  combination  with  spirit  of  nitrous  ether, 
digitalis,  and  decoction  of  fresh  broom-tops.  The  percMoride 
of  mercury  with,  digitalis,  or  the  compound  digitalis  pill 
(containing  blue  pill,  squill,  and  digitalis)  sometimes  answers 
well.  The  digitalis  pill  is  one  that  has  enjoyed  a  long  and 
merited  reputation,  but  it  is  far  more  useful  in  the  treatment  of 
cardiac  than  of  hepatic  dropsy.  Diuresis  will  also  sometimes 
be  induced  by  fomenting  the  abdomen  and  loins  with  an  infusion 
of  digitalis  of  about  four  times  the  Pharmacopoeia  strength.  It 
is  worth  noting  also  that  copaiba  will  occasionally  succeed  in 
increasing  the  flow  of  urine  and  removing  hepatic  dropsy  after 
all  other  diuretics  have  failed.  The  best  form  is  the  resin, 
which  may  be  given  in  doses  of  15  gr.  three  times  a  day.^  By 
acting  on  the  kidneys  there  can  be  no  doubt  that  we  some- 
times succeed  (as  in  Case  CLXII.,  Lect.  XII.)  in  diminishing 
or  retarding  th.e  increase  of  the  ascites  ;  but  when  the  ascites 
is  already  great,  it  must  be  confessed  that  diuretics  are  of 
little  avail,  and  that  in  fact  they  fail  to  increase  the  flow  of 
urine. 

c.  Tonics,  such  as  quinine  and  iron,  sometimes  appear  to 
remove  hepatic  dropsy  after  all  the  more  common  measures 
have  failed.  According  to  Dr.  Bristowe,^  they  are  the  only 
remedies  that  have  succeeded  in  his  hands ;  and  although  this 
has  not  been  my  experience,  I  have  seen  good  results  from  a 
combination  of  the  tincture  of  perchloride  of  iron  with  digi- 
talis, or  from  the  tartrates  of  iron  and  potash  with  digitalis. 

•  The  resin  is  to  be  "n-ell  ruLbed  with  twice  its  weight  of  eompoimd  powder  of 
almonds,  and  an  ounce  of  water  added,  so  as  to  form  an  emulsion.  See  Lancet,  Feb. 
27,  1869  ;  Trans.   Clin.  Soc.  1869,  vol.  iii,  p.  26  ;  Guy's  Hosp.  Eep.  1876,  vol.  ssi. 

2  Trans.  Clin.  Soc.  vol.  ii.  p.  12. 


288  CONTRACTIONS    OP    THE    LIVER.  lect.  viii. 

d.  Collections  of  fluid  in  the  abdomen  are  sometimes  rapidly 
absorbed  after  the  abdomen  has  been  kept  covered  for  some 
time  with  lint  smeared  with  linimentum  hj'drargyri,  to  which 
belladonna  may  be  advantageously  added  if  there  be  much  pain. 
This  good  result,  however,  is  more  likely  to  ensue  when  the 
fluid  results  from  chronic  inflammation  than  when  it  is  caused 
by  portal  obstruction. 

e.  Notwithstanding  the  use  of  these  various  remedies,  the 
ascites  too  often  slowly  increases,  and  sooner  or  later  the  belly 
attains  such  a  size  as  to  serionsly  embarrass  the  breathing  and 
necessitate  a  recourse  to  paracentesis.     The  tapping  may  have 
to  be  frequently  repeated,  and  the  rule  commonly  laid  down  is 
always  to  delay  it  as  long  as  possible,  until  in  fact  there  is 
danger  of  the  respiratory  function  becoming  seriously  inter- 
fered with  by  the  pressure  of  the  fluid.     It  is  argued  that,  as 
the  fluid  collects  again  rapidly,  the  frequent  repetition  of  the 
operation  must  increase  the  patient's  exhaustion,  owing  to  the 
great  drain  of  albumen  from  the  blood  which  the  reaccumulation 
entails.     But   there  are  good    grounds  for  reconsidering  this 
rule.      The   operation   when  delayed   until   the   last   is   often 
followed  by  rapid    sinking  with  typhoid  symptoms.     On  the 
other  hand  the  advantages  of  early  tapj^ing  are,  that  by  removal 
of  pressure  the  establishment  of  a  collateral  circulation  through 
the  more  health 3^  portions  of  the  liver  itself,  as  well  as  through 
the  veins  of  the  abdominal  parietes,  is  promoted.     Secondly,  the 
functions   of  important   parts   which   had   been   impaired   or 
arrested  by  the  pressure  are  restored.     Not  only  are  the  lungs 
relieved,  but  by  the  removal  of  pressure  from  the  portal  and 
renal  veins,  assimilation  and  the  secretion  of  urine  are  increased. 
I  have  known  hcemorrhage  from  the  bowels  arrested  by  para- 
centesis in  cirrhosis,  and  it  is  a  common  observation  that  patients 
with  much  ascites,  who,  notwithstanding  the  most  powerful 
diuretics,  have  been  passing  only  a  small  quantity  of  ui'ine 
containing  much  albumen,  will,  after  paracentesis  and  indepen- 
dently of  drugs,  void  large  quantities  of  urine  free  from  albumen. 
And  thirdly,  diuretic  and  other  remedies,  which,  when  the  ab- 
domen is  full  of  fluid  have  produced  no  effect,  probably  from  not 
being  absorbed,  will  often  after  paracentesis  act  powerfully,  and 
thus  retard  or  prevent  the  reaccumulation  of  fluid  in  the  peri- 
toneum.    As  soon,  therefore,    as   the   abdomen   becomes   mo- 
derately distended  with  fluid,  and  the  remedies  which  I  have 
mentioned  to  you  fail  to  produce  any  effect,  I  would  recommend 


I.KCT.  viti.  CHRONIC    ATROPHY.  289 

you  to  lose  no  time  in  having  recourse  to  paracentesis.^  Even 
should  the  fluid  reaccumulate  repeatedly  you  need  not  despair. 
In  Case  CXV.  the  patient  was  tapped  four  times,  and  after  the 
fourth  tapping  there  was  no  accumulation  of  fluid ;  while  not 
long  ago  a  case  of  cirrhosis  was  reported  by  Dr.  Lyons  of 
Dublin  in  which  the  patient  was  tapped  thirty-six  times  at 
intervals  of  three  weeks  or  a  month,  from  14  to  16  quarts  of 
fluid  being  drawn  off  on  each  occasion  ;  one  year  after  the  last 
tapping,  the  ascites  was  stationary. ^  In  performing  the 
operation,  there  are  one  or  two  particulars  which  I  would 
advise  your  attending  to.  First,  the  trocar  ought  to  be  of 
much  smaller  size  than  that  which  is  commonly  employed,  and 
flattened  instead  of  rounded  ;  the  Avound  resulting  from  such  an 
instrument  is  closed  without  difficulty.  And  secondly,  it  is 
better  not  to  attempt  to  empty  the  peritoneum  at  each  opera- 
tion ;  mischief  sometimes  results  from  the  pressure  necessary 
to  effect  this,  and  all  the  good  effects  of  the  operation  will  be 
obtained,  although  two  or  three  pints  of  fluid  remain.  In  connec- 
tion with  this  subject  T  would  call  your  attention  to  some  in- 
teresting observations  of  Professor  Leudet  of  Rouen,^  who  advo- 
cates the  employment  of  an  exploratory  trocar  for  drawing  off 
the  fluid.  In  two  cases  which  he  has  published  the  instrument 
was  inserted  into  a- protrusion  of  the  umbilical  cicatrix.  This 
procedure  had  these  advantages :  the  integuments  at  the  seat 
of  puncture  were  very  thin ;  the  opening  readily  closed ;  and  the 
instrument  did  not  enter  the  general  cavity  of  the  peritoneum. 

/.  When  there  is  much  oedema  of  the  legs,  as  well  as  ascites, 
both  may  be  relieved  by  acupuncture  of  the  legs,  or  by  making 
an  incision  through  the  skin  into  the  areolar  tissue  about  an 
inch  above  the  inner  ankle  of  each  leg,  followed  by  poultices, 
according  to  the  plan  recommended  many  years  ago  by  a 
distinguished  physician  of  this  (St.  Thomas's)  hospital,  Dr. 
Mead.  The  quantity  of  serum  which  will  sometimes  drain 
away  from  these  punctures  or  incisions,  to  the  great  relief  of 
the  patient,  is  surprising. 

4.  Intercurrent  attacks  of  peri-hepatitis  may  require  local 
depletion,  cataplasms,  and  opium. 

5.  Attacks  of  gastritis  will  demand  sinapisms  and  blisters 

'  For  additional  remarks  on  the  advantages  of  early  tapping  in  ascites,  see  paper 
by  Dr.  John  McCrea,  Dub.  Journ.  of  Med.  Sc,  Aug.  1873 ;  also  Brit.  Med.  Journ. 
1873,  vol.  L  pp.  185,  250. 

-  Erit.  Med.  Journ.  1873,  i.  185.  ^  Clin.  Med.  Paris,  1874,  p.  567. 

tr 


290  CONTEACTIOKS    OP    THE    LIVER.  i.kct.  viii. 

to  tlie  epigastrium,  with  ice  and  lime  water,  or  bismutli  and 
hydrocyanic  acid  internally.  The  diec  should  consist  of  milk 
and  farinaceous  articles  ;  and  when  the  vomiting  is  urgent,  it 
should  be  restricted  to  milk.  Wine  and  spirits,  which  are  often 
taken  under  such  circumstances,  and  which  may  give  temporary 
relief,  alwaj'S  do  harm.  If  their  employment  is  considered 
absolutel}'  necessary,  they  ought  to  be  given  by  the  rectum. 
After  all  other  measures  have  failed,  four  or  five  grains  of 
calomel  will  sometimes  at  once  arrest  the  sickness. 

6.  In  enteritis  it  may  be  necessary  to  apply  a  few  leeches 
round  the  anus,  and  to  administer  the  vegetable  or  mineral 
astringents  with  opium,  and  in  particular  the  acetate  of  lead 
with  morphia,  but  it  is  inexpedient  to  check  the  purging  too 
hastily  or  too  completely. 

7.  When  copious  haemorrhage  occurs  from  the  stomach  or 
bowels,  the  remedies  indicated  are  ice,  ergot,  a  combination  of 
saline  purgatives  and  astringents,  such  as  a  mixture  containing 
sulphate  of  magnesia,  tannin,  and  sulphuric  acid,  and  the  appli- 
cation of  leeches  round  the  anus. 

8.  Flatulence  is  often  a  source  of  so  great  distress,  and 
aggravates  so  much  the  dyspnoea  arising  from  the  ascites,  as  to 
call  for  treatment.  It  will  often  be  relieved  by  the  various 
ethers  and  the  essential  oils  of  peppermint,  anise,  or  cajeput, 
by  vegetable  charcoal,  or  by  galbanum  and  assafoetida.  Inas- 
much, however,  as  it  is  probably  due  to  decomposition  from 
deficient  or  deteriorated  bile,  those  remedies  will  be  found  most 
useful  which  act  by  checking  decomposition,  such  as  creasote, 
turpentine,  or  carbolic  acid  (see  p.  215). 

9.  When  cerebral  symptoms  and  other  signs  of  blood- 
poisoning  supervene,  no  treatment  will  probably  be  of  any  avail, 
but  I  have  known  great,  though  temporary,  improvement  result 
from  calomel  and  saline  purgatives,  and  from  blisters  to  the  scalp. 

The  princijiles  of  troatment  which  have  been  recommended 
for  cirrhosis  are  applicable  to  the  other  forms  of  chronic 
atrophy  of  the  liver,  with  the  following  modifications. 

a.  In  atrophy  of  the  liver  resulting  from  disease  of  the 
heart,  the  treatment  of  the  symptoms  of  obstructed  portal  cir- 
culation must  be  subsidiary  to  that  of  the  more  important  pri- 
mary disease  in  the  chest.  Diuretics  are  more  efFectual  in  remov- 
ing the  dropsy,  and  especially  the  compound  digitalis  pill  (see  p. 
287)  j  but  even  here,  although  alcoholic  stimulants  will  be  more 


LKCT.  VIII.  CHEONIC    ATROPHY.  29 1 

necessary  tlian  in  true  cirrhosis,  thej  must  be  gi^en  with 
caution  (see  p.  135). 

h.  In  cases  with  a  marked  sj^philitic  history,  and  where 
there  is  reason  to  infer  the  presence  of  syphilitic  i^eri-hepatitis, 
mercury  and  iodide  of  potassium  may  be  expected  to  be  of 
service. 

I  shall  now  narrate  to  you  a  few  cases  of  chronic  atrophy 
of  the  liver,  in  illustration  of  the  remarks  which  I  have  made 
respecting  its  pathology  and  treatment.  The  first  is  a  good 
example  of  true  cirrhosis  from  spirit-drinking. 

Case  CIV.  — History  of  Spirit -drinJdug  and  Si/inptoms  of  Portal  Ohstruc- 
tio  i — Dense  fibrous  granular  Liver — True  Cirrhosis. 

Thomas  B ,  aged  52,  a  batcher,  admitted  into  Middlesex  Hosp. 

April  30,  1867.  His  father  and  mother  had  lived  to  an  advanced 
age  ;  a  brother  and  sister  had  died  of  consumption.  He  was  a  large, 
stout  man,  had  always  enjoj'ed  good  health  until  about  two  years  ago, 
Avhen  he  began  to  suffer  from  flatulence,  and  during  last  year  he  had 
also  complained  of  shortness  of  breath,  disturbed  sleep,  chilliness,  and 
occasional  palpitation ;  at  same  time  he  had  noticed  some  swelling  of 
legs  and  abdomen.  He  thought  that  this  swelling  had  gone  away  after 
two  or  three  weeks,  but  about  four  months  ago  it  had  reappeared,  and 
had  since  increased  considerably.  He  said  that  it  had  first  reappeared 
in  left  leg,  but  pos.sibly  it  was  not  greater  in  this  situation  than  else- 
where, and  his  attention  had  been  more  directed  to  it  owing  to  a  vesi- 
cation which  appeared  over  left  ankle.  He  had  never  had  htemorrhoids, 
but  on  several  occasions  during  last  two  years  he  had  vomited  about 
a  teacupful  of  black  blood.  His  habits  had  been  always  intemperate  ; 
he  had  drunk  freely  both  spirits  and  beer. 

On  admission  patient  exhibited  an  emaciated,  sallow  countenance, 
with  a  slightly  jaundiced  tint  of  conjunctivae  and  venous  stigmata  on 
cheeks.  Great  oedema  of  lower  extremities  and  scrotum  and  evidence 
of  a  large  accumulation  of  fluid  in  peritoneum,  umbilicus  being  quite 
obliterated,  and  girth  of  abdomen  being  40  in.  There  was  also  con- 
siderable enlargement  of  subcutaneous  veins  of  abdomen,  especially 
on  right  side.  Hepatic  dulness  diminished  in  right  mammary  line, 
being  less  than  3  in.  (see  fig.  27,  p.  278)  ;  the  splenic  dulness  was  in- 
creased, measuring  vertically  4  in.  No  jaundice,  except  the  slight 
icteroid  tint  of  conjunctivse  above  referred  to.  'No  tenderness  of  ab- 
domen, nor  vomiting  ;  tongue  moist,  with  a  white  fur;  bowels  very 
costive,  often  not  acting  for  a  week  ;  heart's  action  feeble,  but  dulness 
and  sounds  normal.  Pulse  120.  Crepitus,  at  some  places  rather  fine, 
audible  over  lower  half  of  both  lungs,  back  and  front,  but  no  decided 
dulness,  nor  tubular  breathing ;  respirations  36.  Urine  acid,  no  al- 
bumen, but  a  decided  reaction  of  bile-pigment :  specific  gravity  1032. 

V  2 


292  CONTEACTIONS    OF    THE    LIVER.  lect.  -viii. 

Patient  was  treated  with  purgatives  and  diuretics,  bnt  no  improve- 
ment took  place  in  his  condition  ;  on  contrary  dropsy  increased  in  legs, 
and  on  May  17  girth  at  umbilicus  was  47-|-  in. ;  but  head,  neck, 
arms,  and  chest  were  free  from  oedema.  Dyspnoea  increased,  and 
mucus  much  streaked  with  red  blood  was  expectorated.  Urine  was 
very  scanty,  but  free  from  albumen,  having  been  tested  daily  till  May 
17.  Patient  gradually  grew  weaker,  and  on  evening  of  May  18 
he  became  suddenly  much  worse  ;  pulse  very  quick  (136)  and  irregu- 
lar :  very  restless  and  delirious,  and  tongue  dry  and  brown  ;  bowels 
relaxed.  There  Avas  no  increase  of  dyspnoea,  no  lividity  of  face,  and 
no  alteration  in  physical  signs  of  lungs.  Patient  continued  much  in 
same  state  until  his  death  at  11  a.m.  of  following  day. 

On  post-mortem  examination,  great  lividity  and  puffy  sAvelling  of 
face  and  neck,  and  brownish  staining  of  integuments  along  course  of 
subcutaneous  veins.  Heart  was  healthy  ;  no  ap^^earance  of  pleurisy  or 
pneumonia,  but  both  lungs  very  congested  and  oedematous  ;  peritoneum 
contained  several  gallons  of  slightly  turbid,  straw-coloured  serum. 
NotAvithstanding  absence  of  albuminuria,  both  kidneys  much  enlarged, 
right  weighing  0  oz.  and  left  9j  oz. ;  capsiiles  non-adherent,  and  sur- 
faces smooth  ;  cortex  hypertrophied,  flabby  and  soft,  and  mottled  with 
numerous  small,  dark,  ecchymotic  spots  ;  renal  epithelium  loaded  with 
fine  granules,  but  contained  little  oil.  Spleen  large  and  soft,  and 
weighed  7  oz. 

Liver  very  small  and  quite  hidden  below  right  ribs.  It  measui'ed  9 
in.  from  right  to  left ;  antero-jiosterior  diameter  of  right  lobe  was  6^  in. 
and  of  left  5  in. ;  weight  was  43|  oz.  avoird.  Outer  surface  nodulated 
and  granular,  and  presented  the  typical  characters  of  cirrhosis. 
Ca[)sule  not  thickened  nor  adherent ;  structure  much  increased  in 
density,  and  on  section  presented  islands  of  light  yellow  secreting 
ti.s.sue,  cells  of  which  contained  much  oil,  surrounded  by  bi'oad  bands 
of  firm  white  tissue  including  bile-ducts  and  hepatic  vessels.  Gall- 
bladder distended  with  4  oz.  of  thin,  watery,  greenish  bile,  in  which 
were  a  large  number  of  minute  black  concretions  of  insjussated  bile, 
several  of  which  were  also  found  in  cystic,  hepatic,  and  common  ducts. 
Fajces  in  intestines  were  coloured  yellow. 

Case  CV.  is  another  illustration  of  true  cirrhosis  arising 
from  spirit-drinking.  The  cerebral  symptoms  were  due  to  the 
complication  of  disease  of  the  kidneys.  The  attacks  of  jaundice 
from  which  the  patient  suffered  Avere  probably  the  result  of 
catarrh  of  the  bile-ducts ;  the  fact  of  their  being  preceded  on 
each  occasion  for  some  days  by  vomiting  pointed  to  antecedent 
irritation  in  the  stomach  and  duodenum.  That  the  jaundice 
was  independent  of  the  cirrhosis  is  shown  by  its  almost  dis- 
appearing before  death,  although  the  symptoms  of  portal 
obstruction  increased. 


LECT.  Till.  CHEONIC    ATROPHY.  293 

Case  CV. — History  of  Spirit-drinldng — GirrJwsis  of  Liver — Nepliritls — 
Epileptiform  Convulsions,  and  Death  by  Uraemia. 

Derby    H ,    aged   45,    admitted   into  Middlesex    Hospital    on 

Ocober  15,  1867.  He  was  a  barman,  and  for  six  or  seven  years  he 
had  been  in  the  habit  of  drinking  large  quantities  of  gin,  and  during 
last  six  months  he  had  been  very  often  intoxicated.  About  two  years 
before  admission  he  began  to  suffer  from  attacks  of  vomiting,  followed 
after  a  few  days  by  temporary  jaundice,  but  not  accompanied  by  pain 
like  that  of  biliary  colic.  Twelve  months  before  admission  vomiting 
became  more  constant  and  urgent,  especially  in  the  morning,  and  was 
accompanied  by  diarrhoea  and  by  a  persistent  pain  in  region  of  liver 
and  shght  jaundice;  vomited  matters  often  contained  blood.  He  had 
also  several  attacks  of  epistaxis,  one  of  which  was  so  severe  that  he 
was  taken  to  Charing  Cross  Hospital,  where  his  nostrils  were  plugged. 
Six  weeks  before  admission  he  had  a  severe  fit  of  epileptiform  convul- 
sions, in  which  he  bit  tongue  deeply.  In  following  three  weeks  he 
had  four  similar  attacks,  last  of  which  was  followed  by  jaundice,  and  a 
condition  resembling  delirium  tremens,  which  continued  up  to  time  of 
admission. 

On  admission,  patient's  mind  very  confused,  expression  stupid,  and 
considerable  stupor.  Conjunctivae  and  whole  surface  of  body  rather 
deeply  jaundiced,  and  very  slight  pitting  of  lower  extremities.  Tongue 
dry  and  brown  down  centre,  and  on  left  margin,  where  it  had  been 
bitten  in  one  of  fits,  there  was  a  deep  ulcer.  Motions  contained  bile. 
There  was  now  neither  vomiting  nor  diarrhoea,  but  there  was  evident 
tenderness  on  pressure  below  right  ribs.  Liver  could  not  be  felt,  and 
hepatic  dulness  in  right  mammary  line  was  diminished,  not  exceeding 
3  in.  At  margin  of  ribs,  however,  corresponding  to  situation  of  gall- 
bladder, a  distinct  i-ounded  tumour  could  be  felt,  about  size  of  a  hen's 
egg.  Abdomen  much  distended  from  tympanites,  measuring  at  um- 
bilicus 32|  in. ;  no  sign  of  ascites  could  be  discerned,  but  splenic  dul- 
ness increased,  and  &ubcutaneou.s  veins  of  abdomen  enlarged.  Pulse 
84,  feeble  but  regular ;  cardiac  dulness  slightly  increased  towards  left, 
measuring  transversely  2-g-  in. ;  sounds  weak,  but  no  bellows-murmur. 
IS^o  dyspnoea  nor  cough,  and  physical  signs  of  lungs  normal.  Urine  very 
dark,  like  porter  ;  sp.  gr.  1020  ;  it  contained  abundance  of  bile- pigment 
and  a  trace  of  albumen  ;  under  microscope  a  few  blood-corpuscles  were 
seen,  but  no  casts.     Temperature  101"2°. 

Patient  was  treated  with  laxatives,  dia,phoretics,  and  diuretics,  and 
a  simple  diet  without  any  stimulants  ;  he  had  also  several  warm  baths, 
and  mustard  poultices  applied  to  back  of  neck  and  over  region  of  liver. 
Under  this  treatment,  after  two  or  three  days,  he  began  to  improve, 
and  at  end  of  ten  days  he  was  able  to  get  up  and  go  about  ward. 
Jaundice  and  tympanites  Avere  greatly  diminished  ;  tumour  in  region 
of  gall-bladder  had  disappeared,  tongue  was  moist  and  clean,  appetite 


294  CONTKACTIOXS    OF    THE    LIVER.  lect.  viii. 

had  returned,  and  temperature  was  normal.     Urine,  however,  still  con- 
tained a  slight  trace  of  albumen  (o^^),   and  patient's  memory  was  con- 
fused as  to  dates.     With  exception  of  a  painful  inflammatory  swelling 
in  meatus  of  left  ear,  lumbar  pain,  an  attack  of  vomiting  with  slight 
epistaxis  on  Nov.  22,   and  a  retui-n  of  stupor  with  dryness  of  tongue 
during  last  week  of  November,  this  improvement  lasted  until  Dec.  12. 
About  this  time  he  became  much  weaker,  and  very  restless  and  delirious 
at  night ;  abdomen  had  again  enlarged,  measuring  at  umbilicus  35|-  in., 
and  there  was  now  unmistakable  evidence  of  a  small  quantity  of  fluid 
in  peritoneum,     Thei'e  was  also  considerable  oedema  of  lower  extremi- 
ties, and  a  distinct  systolic  blowing  murmur  at  base  of  heart.     The 
albumen  in  uiine,  however,  was  not  increased ;  temperature  was  only 
96°  F.,  and  there  was  scarcely  any  jaundice.     Treatment  consisted  in 
administration  of  liquor  ammonia?  acetatis  with  acetate  of  potash,  tinc- 
ture of  digitalis,  and  decoction  of  broom-tops  with  mild  laxatives,  and 
subsequently  compound  jalap  powder  and  croton  oil,  and  application 
of  mustard  and  linseed  poultices  to  loins.     Ascites,  however,  gradually 
increased  until  abdomen  measured  40  in.,  but  after  patient  kept  his  bed 
dropsy  of  legs  almost  disappeared,  and  there  was  no  trace  of  dropsy  of 
face  or  upper  part  of  body.     Enlargement  of  abdominal  veins  increased, 
urine  was   scanty  and  smoky,  and  contained  a  much  larger  amount  of 
albumen  (^),  with  epithelial  and  blood-casts.     Tongue  dry  and  brown  ; 
motions  and  urine  passed  in  bed;  temperature  throughout  was  rather 
below  normal  standard.     For  three  or  four  days  before   death,  which 
took  place  on  Dec.  23,  much  noisy  incoherent  delirium  with  spasmodic 
twitchings  of  extremities,  but  no  general  convulsions. 

The  appearances  found  after  death  were  as  follows  : — Slight  jaun- 
dice of  integuments.  Several  quarts  of  clear  straw-coloured  serum  in 
peritoneum.  Liver  very  small,  measuring  only  9  in.  from  right  to 
left,  and  6  in,  from  back  to  front,  in  right  lobe  ;  greatest  thickness 
3;^  in.  ;  weight  44  oz.  ;  outer  surface  coarsely  granular ;  glandular 
substance  extremely  dense,  and  consisting  of  firm  bands  of  fibrous 
tissue,  including  bile-ducts  and  obliterated  vessels,  and  enclosing  islets 
of  yellow  secreting  tissue,  colls  in  which  were  loaded  with  yellow 
pigment  and  oil.  Spleen  large,  7  oz.,  firm.  Pancreas  very  large; 
and  indurated  from  presence  of  an  unusual  amount  of  fibrous  tissue. 
Extreme  catarrhal  inflammation,  with  ha^morrhagic  erosions,  of 
mucous  membrane  of  stomach.  Both  kidneys  enlarged,  weighing 
together  14  oz. ;  capsules  separating  readily ;  surfaces  smooth  ; 
cortices  hypertrophied ;  marked  injection  of  straight  vessels  in  pyra- 
mids and  of  Malpighian  bodies;  renal  tubes  gorged  with  granular 
epithelium.  Considerable  hypertrophy  of  left  ventricle  of  heart,  and 
a  vegetation  the  size  of  a  hemp-seed  on  ventricular  surface  of  each  of 
aortic  valves.  .Much  hypostatic  congestion  of  both  lungs,  and  a  few 
ol  I  adiiesions  over  surface  of  left.  Much  scrtnis  fluid  containir.g 
urea  beneath  arachnoid  and  in  lateral  ventricles  of  brain. 


LBCT.  viii.  CHRONIC    ATROPHY.  295 

In  the  following  case  there  wrs  every  reason  to  believe  from 
the  liistory  that  the  atrophy  of  the  liver  was  due  to  true 
cirrhosis,  but  the  only  indications  of  portal  obstruction  were 
copious  hsematemesis,  hsemorrhoids,  and  slight  enlargement  of 
the  spleen.  In  several  instances,  however,  I  have  known  persons 
die  suddenly  of  hsematemesis,  who  had  previously  been  suflS.- 
ciently  well  to  perform  their  duties  in  life,  and  in  whose  bodies 
well-marked  cirrhosis  of  the  liver  has  been  found  after  death. 
The  treatment,  though  successful,  was  not  such  as  I  would 
recommend  to  you  in  similar  cases  (p.  290). 

Case     CVI. — History    of    Sjnrit-drinhmg — Contracted    Liver — Copious 
Hcematemesis — Delirium  Tremens. 

Eliza  D ,  aged  29,  a  person  in   good  circumstances,  admitted 

into  Middlesex  Hosp.  Feb.  5,  1867.  Had  been  married  for  five  years, 
and  was  mother  of  two  children.  Ever  since  her  marriage,  and  per- 
haps before,  she  had  been  addicted  to  spirit- drinking.  This  had  led 
to  a  separation  from  her  husband.  For  a  long  time  she  had  been  in 
the  habit  of  getting  drunk  two  or  three  times  a  week.  She  had  not 
suffered,  however,  from  pain  and  vomiting  after  food. 

Early  in  morning  of  day  of  admission,  after  a  restless  night, 
patient  vomited  mucus  streaked  with  blood,  and  an  hour  aftervi'ards 
she  brought  up  a  large  quantity  of  pure  blood.  The  medical  man  who 
was  called  to  see  her  said  that  there  were  at  least  two  pints.  Brandy  and 
ice  were  administered,  but  she  vomited  more  blood,  and  on  trying  to 
get  up,  she  fell  down  insensible,  and  was  brought  to  hospital  at  noon. 

On  admission,  skin  was  noted  to  be  sallow,  although  there  was  no 
decided  jaundice.  Tenderness  at  epigastrium ;  hepatic  dulness  di- 
minished, not  amounting  to  3  in.  in  right  mammary  line;  splenic 
dulness  increased ;  several  small  heemorrhoids  about  anus ;  but 
neither  ascites  nor  enlaro-eraent  of  abdominal  veins.     Urine  contained 

o 

a  trace  of  albumen  ;  a  faint  systolic  bellows-murmur  over  heart,  but 
cardiac  dulness  and  impulse  not  increased ;  physical  signs  of  lungs 
normal ;  no  oedema  of  legs. 

Patient  was  treated  with  gallic  acid  and  opium,  and  with  ice  and 
milk,  but  no  stimulants.  For  several  days  vomiting  continued,  but, 
except  on  day  of  admission,  vomited  matters  contained  no  blood. 
Bowels  did  not  act  for  five  days  after  admission  ;  enemata  then 
brought  away  a  large  quantity  of  tar-like  matter.  For  several  days 
after  admission  patient  suffered  from  a  severe  attack  of  delirium  tre- 
mens, but  by  Feb.  11  this  had  quite  subsided,  and  she  was  able  to  eat 
and  retain  solid  food.  Vomiting  did  not  recur,  and  on  Feb.  16  she 
was  discharged. 

The  interest  of  Case  CVII.  consisted  in  this,  that  the  patient 


296  CONTRACTIONS    OF    THE    LIVER.  lect.  vm. 

appeared  to  be  in  good  health  until  the  sudden  occurrence  of 
copious  hsematemesife,  ^yhicll  was  speedily  followed  by  ascites 
and  death. 

Case  CVII. — Cirrhusis — Persistent  Hcematemesls  the  first  notahle 
symptom — Ascites. 

Thomas  B — — •,  aged  53,  a  bargeman,  adm.  into  St.  Thomas's 
Hosp.  April  18,  1874.  Father  alive  and  in  good  health,  nearly  70; 
mother  died  at  43.  He  was  an  only  child,  and  up  to  age  of  43  he  had 
been  repeatedly  in  tropics  and  had  suffered  from  dysentery  and  mala- 
rious fevers,  and  pain  in  region  of  liver.  He  had  not  led  a  temperate 
life,  but,  with  exception  of  constipation  and  some  distension  of  abdomen 
which  came  and  went,  he  had  enjoyed  good  health  until  early  in  morn- 
ing of  March  24,  Avhen  he  vomited  several  pints  of  dark  blood.  Next 
day  he  again  vomited  a  large  quantity  of  blood,  and  from  then  until 
admission  he  had  continued  to  vomit  food  and  mucus  night  and  morn- 
ing. Abdomen  had  enlarged  steadily',  and  bowels  been  contined,  but 
no  pain.     Legs  began  to  swell  a  few  days  before  admission. 

Admitted  on  account  of  a  return  of  haemorrhage.  Countenance 
sallow  with  enlargement  of  cutaneous  veins  of  cheeks,  but  conjunctivae 
white.  Slight  oedema  of  legs.  Abdomen  greatly  distended  from  fluid 
in  peritoneum,  measuring  at  umbilicus  40-^  in.  ;  not  tender.  Abdomi- 
nal veins  much  enlarged.  Hepatic  dnlness  commenced  half-an-inch 
below  right  nipple  ;  lower  margin  could  not  be  made  out.  Constant 
vomiting;  food  at  once  rejected;  vomited  matter  also  contained  much 
blood,  partly  in  coagula  and  partly  mixed  with  viscid  mucus  ;  motions 
passed  after  medicine  black  and  very  offensive.  Tongue  pale,  devoid 
of  epithelium,  fissured  and  dry  down  centre;  much  belching  of  gas. 
Urine  scanty,  1035,  high-coloured  and  loaded  with  lithates.  Pulse 
104,  regular  but  feeble  ;  heart  displaced  upwards ;  no  abnormal  mur- 
mur. Frequent  cough,  and  a  few  bronchial  rales  over  lungs.  Sleep 
much  disturbed.     Temp.  97"8^. 

Was  ordered  ten  grains  of  calomel  followed  by  citnite  of  magnesia, 
and  a  mixture  of  bismuth  and  soda,  with  milk  and  soda-water.  Sub- 
sequently small  quantities  of  stimulants  were  given,  and  the  subcu- 
taneous injection  of  ergotin  was  tried  to  check  the  hajmorrhage. 
Ha3morrhage,  however,  from  stomach  and  bowels  persisted,  and 
patient  became  daily  weaker  and  more  antemic.  On  morning  of 
April  24  he  was  extremely  low,  temperature  being  only  9G"3°,  and  at 
11  I'.M.  he  died. 

Autopsy. — About  20  pints  of  serous  fluid  in  peritoneum.  Peri- 
toneum generally  thickened,  and  numeious  Arm  adhesions  connecting 
liver  with  diaphragm,  stomach,  and  other  parts.  Spleen  large,  and 
also  adherent.  Capsules  of  spleen  and  liver,  and  omentum  and  mesen- 
tery, much  thickened.     Liver  very  small  ;  after  removal  of  capsule, 


i.ECT.  Till.  CHEONIC    ATROPHY.  297 

surface  nodulated ;  on  section  firm  fibrous  bands  separated  yellow 
islets  of  secreting  tissue.  Black  tarry  niattef  in  colon.  Heart  and 
kidneys  healthy.  Lungs  adherent  at  bases  and  oedematous.  Brain 
anemic. 

Many  of  you  watclied  the  patient,  whose  case  I  am  now  about 
to  relate,  with  much  interest,  and  it  is  to  be  regretted  that  no 
opportunity  was  afforded  for  examining  the  condition  of  his 
liver  after  death,  inasmuch  as  there  was  considerable  obscurity 
as  to  the  cause  of  the  atrophy.  The  signs  of  obstructed  portal 
circulation,  however,  were  well  marked,  and  the  circumstance 
of  hsematemesis  preceding  the  other  signs  of  obstruction,  for 
several  years,  is  interesting  in  connection  with  what  was 
observed  in  Cases  CVI.  and  CYII. 

Case    CVIII. — Chronic   Atroplnj  of  Liver — Ascites — Hcematemesis  and 

Bloody   Stools. 

James  T ,  aged  38,  was  adm.  into   Middlesex  Hosp.  Aug.   20, 

1866.  For  six  years  lie  had  been  a  brewer's  drayman,  and  been  accus- 
tomed to  drink  a  good  deal  of  ale,  but  not  spirits  ;  before  that  he  had 
been  a  farm  labourer  and  had  drunk  little  of  alcohol  in  any  shape.  He 
had  never  sufiered  from  ague  or  rheumatic  fever,  but  at  age  of  18  he  had 
been  laid  up  for  a  year  with  a  cough  and  debility,  and  had  been  told 
at  the  Reading  Infirmary  that  he  had  consumption.  He  recovered, 
however,  and  remained  well  until  eight  years  before  admission,  when 
he  received  a  kick  from  a  horse  on  right  side.  He  did  not  take  much 
notice  of  this  at  the  time,  and  followed  his  work  for  five  or  six  Aveeks 
afterwards.  Whether  owing  to  this  injury  or  not,  he  then  began  to 
sufier  I'rom  great  pain  and  tightness  at  epigastrium,  with  constipation. 
He  took  some  aperient  medicine,  which  operated,  but  on  following  day 
he  vomited  a  large  quantity  of  clotted  blood,  and  for  a  week  afterwards 
he  continued  to  pass  blood  per  anum.  This  left  him  very  weak,  but 
relieved  pain,  and  he  returned  to  work.  After  this  he  had  a  similar 
attack  about  once  a  year,  only  difference  being  that  quantity  of  blood 
lost  was  less  than  it  had  been  the  first  time.  On  each  occasion  vomit- 
ing of  blood  had  been  preceded  for  several  days  by  great  headache, 
nausea,  and  pain  in  abdomen.  Last  attack  had  occurred  four  months 
before  admission.  In  spring  of  1 865  he  had  been  for  several  weeks  in 
a  metropolitan  hospital  for  htemorrhage.  Shortly  after  leaving  that 
hospital,  in  April  1805,  abdomen  became  swollen,  and  subsequently, 
his  legs.  He  drank  '  broom-tea,'  and  swelling  subsided,  but  a  month 
before  admission  it  increased  again. 

On  admission,  patient  was  emaciated  and  sallow,  but  conjunctivce 
were  white.  Abdomen  greatly  distended  from  fluid  in  peritoneum,  and 
veins  of  abdominal  wall  imusually  large  and  distinct,  but  nowhere 


298  CONTRACTIONS    OF    THE    LIVER.  lect.  viii. 

tenderness,  except  on  pressure  over  right  liypochondrium.  Liver  could 
not  be  felt,  and  hepatic  dulness  in  right  mammfay  line  measured  only  -^ 
in.,  an  observation  which  was  subsequently  confirmed  after  paracentesis. 
Tongue  slightly  furred  ;  bowels  costive  ;  slight  flatulence  after  meals  ; 
appetite  good.  An  ansfimic  bellows-murmur  over  sternum ;  cardiac 
dulness  not  increased.  Respirations  20,  and  easy ;  at  bases  of  both 
lungs  a  little  fine  crepitation.  Upwards  of  40  oz.  of  urine  were  passed 
daily ;  it  was  dark,  but  contained  neither  albumen  nor  bile-pigment. 
Moderate  oedema  of  both  legs. 

Ti'eatment  consisted  in  purgatives  and  diuretics,  and  for  some  time 
bromide  of  potassium  in  five-gi'ain  doses  three  times  a  day.  A 
generous  diet  Avas  allowed,  but  no  stimulants.  At  first  there  Avas  con- 
siderable improvement,  and  girth  of  abdomen  was  reduced  2  in. ;  .but 
about  middle  of  September  swelling  increased  again,  and  on  28th  ab- 
domen measured  42  in.,  integuments  over  it  were  tight  and  glistening, 
and  urine  was  reduced  to  about  a  pint  daily  ;  respirations  32,  and  con- 
siderably embarrassed.  On  Sept.  30  patient  suSered  much  from  pains 
in  abdomen,  and  during  following  night  he  began  to  pass  frequent 
motions  contaiuing  much  black  blood.  On  Oct.  6  patient  had  still 
diarrhoea  with  bloody  stools  ;  abdomen  had  increased  to  44  in.  ;  legs 
also  Avere  SAvollen,  and  great  orthopncea.  Paracentesis  was  performed, 
and  17  pints  of  fluid  were  draAvn  off" ;  fluid  clear,  straw-coloured,  and 
alkaline  ;  specific  gravity  1012  ;  it  contained  a  large  quantity  of  both 
chlorides  and  albumen.  The  operation  gave  great  relief  to  breathing  ; 
anasarca  of  legs  diminished ;  urine  rose  to  two  pints ;  and  blood  dis- 
appeared from  motions.  Two  days,  however,  had  not  elapsed  before 
swelling  Avas  again  noticed  to  be  increasing,  and  on  Oct.  15  abdomen 
measured  42  in.,  oedema  of  lungs  had  extended,  and  patient  suffered 
much  from  dyspnoea  and  cough.  On  Oct.  21  vomiting  came  on  ; 
vomited  matters  contained  a  good  deal  of  blood ;  motions  again 
also  contained  blood.  These  symptoms  continued  until  Oct.  24,  Avhen 
patient  insisted  (ai  leaving  hospital.  He  was  removed  to  Egham,  Avhere 
he  died  the  same  evening.  His  friends  Avould  not  permit  his  body  to 
be  examined. 

In  Case  CIX.,  although  the  liver  Avas  really  much  atrophied, 
it  appeared  during  life  to  be  enlarged  from  being  displaced 
doAvnwards  by  an  accumulation  of  serous  fluid  between  its  upper 
surface  and  the  diaphragm. 

Case  CIX. — Small  Cirrhotic  Liver  displaced  downwards  and  simidating 
Cancer — Ascites  and  Jaundice. 

Agnes  F ,  32,  single,  needlewoman,  adm.  into  Middlesex  Hosp. 

May  29,  18G0.  Aliout  a  year  before  admission  began  to  suffer  from 
loss  of  appetite,  Aveakness  and  languor,  pains  in  abdomen,  and  fulness 
after  eating.     After  four  months  she  had,  in  addition  to  these  sym- 


LECT.  Tin.  CHRONIC    ATEOPHT.  299 

ptoms,  nausea,  eructations  of  sour  frothy  fluid,  and  retching  in  morning. 
Four  weeks  before  admission  a  doctor,  who  had  been  called,  to  see  her 
for  a  wound  of  forehead,  discovered  that  she  had  '  dropsy  in  the 
stomach.'  From  the  statements  of  her  friends  there  seemed  little 
doubt  that  she  had  been  frequently  intoxicated. 

On  admission  was  thin  and  weak,  and  bad  considerable  oedema  of 
lower  extremities.  Peritoneal  cavity  distended  with  fluid,  girth  of  ab- 
domen at  umbilicus  being  36^  in.  Superficial  veins  of  abdomen  en- 
larged. On  abrupt  palpation,  lower  edge  of  what  appeared  to  be  an 
indurated  liver  could  be  felt  distinctly  3  in.  below  ribs  in  right 
nipple  line  ;  contact  of  finger  with  this  always  caused  pain.  There 
was  also  dulness  on  percussion  in  right  nipple  line  for  4  in.  above 
lower  margin  of  ribs.  Decided  jaundice  of  skin  and  conjunctiva. 
Tongue  dry  down  centre  ;  appetite  bad  ;  much  thirst ;  no  retching  ; 
bowels  open,  and  motions  contained  plenty  of  bile.  P.  84  ;  resp.  18  ; 
heart  and  lungs  appeared  to  be  sound  ;  temperature  normal ;  no  rigors 
nor  perspirations.  Sleeps  badly;  expression  vacant;  and  wanders  at 
times.  Urine  1023,  contained  much  lithates  and  bile-pigment,  and  a 
minute  quantity  of  albumen.  On  left  temple  was  a  wound  with  dirty 
swollen  edges,  and  left  cheek  was  ecchymosed. 

After  admission,  patient  continued  to  get  worse.  Jaundice  dimi- 
nished, but  ascites  increased  until  July  14,  when  girth  at  umbilicus 
was  45^  in.  During  last  week  of  June  she  began  to  vomit  food,  and 
to  complain  of  pain  in  abdomen  so  severe  as  to  necessitate  frequent 
subcutaneous  injections  of  morphia.  Delirium  and  restlessness  con- 
tinued, and  pulse  rose  to  120,  but  temperature  was  always  normal. 
Became  gradually  weaker,  and  died  on  July  22. 

A  utopsy. — Peritoneum  contained  many  quarts  of  clear  yellow  serum, 
a  quantity  of  which  had  collected  between  diaphragm  and  upper  sur- 
face of  liver.  That  this  arrangement  had  existed  during  life  seemed 
probable  from  there  being  no  other  explanation  of  fact,  that  liver  had 
been  repeatedly  felt  3  in.  below  ribs,  and  yet  was  pretematurally  small, 
its  weight  being  onl}^  36^  oz.,  its  extreme  length  9  in.,  and  its 
greatest  breadth  7  in.  It  was  a  typical  example  of  true  cirrhosis. 
Spleen  slightly  enlarged,  soft  and  congested.  Mucous  membrane  of 
stomach  intensely  congested.     Lungs,  heart,  and  kidneys  normal. 

After  tlie  operation  of  paracentesis,  fluid  often  continues  to 
drain  away  from  the  opening  for  many  days,  and  the  patient 
dies  from  exhaustion,  or  from  the  supervention  of  peritonitis, 
and  in  Case  CX.  the  attempt  to  close  the  opening  seemed  to  in- 
duce peritonitis.  These  dangers  will  be  avoided  by  employing 
a  small  flattened  trocar,  instead  of  the  large  rounded  instrument 
in  common  use  (see  p.  289). 


300  CONTRACTIONS    OF    THE    LIVER.  lect.  yiii. 

Case  CX. — History  of  Spirit-drinldng — Cirrhosis  of  Liver — Ascites — 
Paracentesis — Patency  of  opening — Attempts  to  close  it  followed  by 
Peritonitis. 

John    L ,   house-agent,  aged  47,  adm.  into   Middlesex  Hosp. 

Dec.  30,  1868.  From  age  of  16  until  three  years  ago  had  been  in  habit 
of  drinking  on  an  average  upwards  of  half  a  pint  of  spirits  daily, 
besides  beer.  Left  off  drinking  spirits  because  it  made  him  vomit  his 
food.  After  this  had  better  health  until  Sept.  9,  when  he  was  kicked 
by  a  horse  in  private  parts,  in  consequence  of  which  he  was  laid  up  in 
hospital  for  2^  months  with  abscess  of  scrotum  followed  by  erysipelas 
of  legs.  On  recovering,  he  began  to  complain  of  pain  in  both  hypo- 
chondria, and  three  weeks  before  admission  abdomen  began  to  swell : 
more  recently  legs  had  become  swollen. 

On  admission,  countenance  spare  and  sallow,  with  stellate  veins 
on  cheeks,  but  no  jaundice  of  conjunctiviB.  Considerable  oedema  of 
legs,  dependent  parts  of  trunk,  penis,  and  scrotum.  Much  fluid  in 
peritoneum;  girth  of  abdomen,  3  in.  above  umbilicus,  4(5  in.  Com- 
plains greatly  of  feeling  of  tightness  in  abdomen.  Abdominal  veins 
enlarged.  Hepatic  dulness  in  r.  m.  1.  3^-  in.  ;  no  appreciable  enlarge- 
ment of  spleen.  Tongue  too  red  ;  fair  appetite  ;  no  vomiting  ;  bowels 
regular.  P.  104,  weak  ;  heart  signs  normal.  Sibilant  rales  and  pro- 
longed expiration  over  both  lungs.  Urine  contained  a  trace  of  albumen 
and  also  of  bile-pigment,  and  mainly  passed  involuntarily.  Two  bed- 
sores over  sacrum. 

Patient  was  in  such  distress  from  distension  of  abdomen  that  on 
Jan.  1  paracentesis  was  performed,  and  16  pints  of  clear  straw-coloured 
serum  drawn  off.  Grreat  relief  followed  operation  ;  but  fluid  continued 
to  drain  away  in  such  large  quantity  from  opening,  that,  on  Jan.  4,  at 
suggestion  of  my  colleague  Mr.  Moore,  this  was  closed  by  a  needle  and 
twisted  suture.  Next  morning  patient  complained  of  nausea  and  of 
pain  in  abdomen,  which  was  also  tender.  In  course  of  day  he  vomited 
frequently,  and  had  all  symptoms  of  acute  peritonitis,  which  continued 
until  death  on  evening  of  Jan.  6. 

Autopsy. — Fully  12  pints  of  turbid  flaky  fluid  in  peritoneum. 
Much  vascularity  and  adherent  recent  lymph  in  neighbourhood  of 
puncture.  Liver  small  and  entirely  concealed  beneath  ribs;  but  very 
dense,  and  weighed  68  oz.  ;  a  typical  example  of  true  cirrhosis.  Spleen 
adherent  and  capsule  thickened.  Both  lungs  emphysematous,  congested 
posteriorly,  and  bronchial  tubes  full  of  muco-pus.  Right  side  of  heart 
somewhat  dilated.     Kidneys  congested,  but  otherwise  healthy. 

Case  CXI.  was  interesting,  as  being  an  example  of  true 
cirrhosis  in  a  boy  aged  9,  and  also  from  the  circumstance  that 
notwitlistanding  his  youth,  the  patient  had  been  addicted  to 
stimulants.     The  diagnosis  was  embarrassed  by  the  fact  that 


LECT.  Till.  CHEONIC    ATEOPHT.  3OI 

the  boy's  habits  were  not  ascertained  until  after  his  death,  by 
the  occasional  rise  of  temperature  at  night,  by  the  tubercular 
family  history,  and  by  slig'ht  crepitation  having  been  noted  at 
the  apex  of  the  left  lung  when  the  boy  was  first  admitted  into 
hospital.  The  occurrence  of  cirrhosis  in  children  has  been 
frequently  appealed  to,  to  show  that  the  disease  is  not  due  to  the 
abuse  of  alcohol,  but  here,  as  well  as  in  another  case  recently 
under  my  care,  what  appeared  at  first  to  be  an  exception,  was 
found  to  confirm  the  rule.  It  is  worth  mentioning  also  that 
Wunderlich  observed  typical  examples  of  cirrhosis  in  two  sisters 
aged  11  and  12,  both  of  whom,  on  careful  enquiry,  were  found 
to  have  been  dram-drinkers.^  Cheadle,  also,  has  recently  re- 
corded a  ease  of  extreme  cirrhosis  in  a  boy  aged  18,  who  had 
been  in  the  habit  of  drinking  large  quantities  of  gin.^  Lastly, 
Dr.  Wilks  had  under  his  care  in  Guy's  Hospital,  not  long  ago,  a 
little  girl  eight  years  old,  suffering  from  what  proved  to  be  a  very 
small  hobnailed  liver;  she  had  been  addicted  to  drink,  having 
taken  as  much  as  half  a  pint  of  gin  daily .^  It  is  possible  that 
the  greater  activity  of  the  liver  in  early  life  may  render  it  more 
liable  to  suffer  from  alcohol  than  in  adults. 

Case  CXI. — True  Girrliosis  in  a  Boy  aged  9 — Ascites — Paracentesis. 

Henry  IST -,  aged  9,  schoolboy,  adm.  into   St.   Thomas's  Hoap. 

Sept.  5,  1875.  Father  alive  and  in  good  health ;  mother  died  of 
phthisis,  and  several  brothers  and  sisters  had  died  in  childhood.  As 
far  as  boy  was  aware,  he  had  always  had  good  health  until  about  two 
months  before  admission.  During  whole  of  July  he  had  suffered  from 
sickness  and  retching  every  morning.  On  Aug.  1  he  had  been  sent  to 
sea-side,  but  the  sickness  persisted,  and  abdomen  began  to  swell.  After 
16  days  he  returned  home  ;  the  sickness  now  ceased,  but  the  swelling- 
increased.  From  first  he  had  been  losing  flesh,  and  bowels  had  been 
rather  confined. 

After  boy's  death  it  was  ascertained  that  his  father  kept  a  small 
public-house,  anrl  ''"  ..t  boy  had  been  in  habit  of  drinking  a  good  deal 
of  wine  an-^  .^er,  especially  between  meals.  While  in  hospital  also, 
he  took  stimulants  with  a  readiness  quite  unusual  in  children. 

On  admission,  boy  was  emaciated,  biit  abdomen  very  large,  owing 
to  fluid  in  peritoneum.  Girth  at  umbilicus  32^  in.  Abdomen  not 
tender.  Lower  margin  of  liver  could  not  be  felt;  upper  margin  not 
too  high.  Spleen  much  enlarged  ;  lower  end  fully  4  in.  beyond  ribs. 
E'o  jaundice  ;  no  cedema  of  legs  ;  no  albuminuria  ;  no  sign  of  constitu- 

'  Niemeyer's  Text  Book  of  Pract.  Med.,  Amer.  Transl.,  i.  641. 

2  Brit.  Med.  Journ.  1871,  ii.  545. 

^  Dr.  Hilton  Fagge,  Guy's  Hosp.  Eep.,  1875,  Ser.  iii,  rol.  xx. 


302  CONTRACTIONS    OF    THE    LIVER.  lect.  viii. 

tional  syphilis,  and  sounds  of  lieart  normal.  Temp,  occasionally  as 
high  as  100'6°.     Eats  and  sleeps  well.     Tongue  normal. 

Boy  was  at  first  treated  with  syrup  of  iodide  of  iron  internally,  Avhile 
tincture  of  iodine  was  painted  over  abdomen.  On  Sept.  8,  and  9, 
temp,  in  evening  rose  to  102"8°  and  103"4°  but  usually  it  was  under 
100°.  On  Sept.  18  girth  at  umbilicus  had  increased  to  [31j  in. 
Citrate  of  ammonia  was  now  substituted  for  the  iron,  and  a  mercurial 
plaster  was  applied  to  abdomen,  while  bowels  were  kept  open.  Under 
this  treatment  ascites  rapidly  diminished,  and  on  Oct.  5  no  trace  of  it 
remained  ;  girth  at  umbilicus  was  only  24  in.,  and  except  that  spleen 
remained  large,  and  he  was  weak,  boy  seemed  well.  He  was  now  treated 
with  iodide  of  potassium  and  iron,  digitalis,  and  cod-liver  oil.  Once 
or  twice  he  was  sick  in  morning,  and  on  Oct.  24  abdomen  seemed  to  be 
swelling  again,  girth  being  25^  in.  After  this  swelling  rapidly  in- 
creased until,  on  Nov.  10,  girth  was  again  341  in.  and  tongue  red 
and  dry.  Bile  in  urine.  Digitalis  and  iodide  of  potassium,  with 
aperients,  produced  no  effect ;  and  on  Nov.  12  gii-th  37^  in.,  integu- 
ments of  abdomen  smooth  and  shiuing.  Pulse  120  ;  respirations  60, 
embarrassed.  Fifteen  pints  of  clear  straw-coloured  serum  were  drawn 
oflf  by  paracentesis,  and  patient  was  ordered  blue  pill,  squill,  and 
digitalis,  and  saline  diuretics.  The  fluid  rapidly  reaccumulated,  and 
on  Nov.  24  girth  38  in.  ;  pain  in  abdomen  and  occasional  vomiting ; 
considerable  oedema  of  legs ;  extreme  dyspnoea  and  prostration. 
Paracentesis  again  performed,  and  16  pints  of  fluid  drawn  off,  with 
temporary  relief ;  but  next  day  patient  complained  of  intense  pain  in 
abdomen  and  nausea,  and  abdomen  was  refilling  ;  at  7  P.ii.  collapse 
came  on,  and  at  11.20  p.m.  he  died. 

Autopsy. — Peritoneum  contained  6\  pints  of  opaque  ascitic  fluid, 
containing  a  few  flakes  of  lymph.  Peritoneum  generally  much  in- 
jected. Great  omentum  matted  into  a  mass  adherent  to  adjacent  in- 
testines ;  mesentery  thick  and  oedematous.  No  tubercle.  Liver  small ; 
it  weighed  21-^  oz.,  normal  weight  for  patient's  age  being  about  32  oz. ; 
outer  surface  presented  typical  hobnailed  character  of  cirrhosis; 
numerous  small,  irregular,  yellowish  prominences,  separated  by  pinkish 
grey  depressions.  Substance  very  hard,  tough  and  leathery.  On 
section,  yellowish  islets  of  secreting  tissue  surrounded  by  fibrous  bands. 
Gall-bladder  contained  normal  bile.  Spleen  large ;  weighed  10  oz.  ; 
deep  red,  firm.  Mucous  membrane  of  stomach  thickenetl,  deeply  injected, 
and  with  much  adherent  viscid  mucus.  Lower  part  of  ileum  congested. 
Peycr's  patches  and  solitary  glands  of  hirge  intestine  slightly  enlarged. 
Kidneys  large  and  congested,  but  structure  normal.  Heart  and  lungs 
normal,  with  exception  of  some  hypostatic  congestion  of  both  lungs  and 
small  ecchymoses  in  subpleural  tissue. 

The  two  livers  which  I  now  show  you  appear  to  me  to 
account  for  certain  differences  of  opinion  still  entertained  re- 


lECT.  vm.  CHRONIC    ATROPHY.  303 

specting  the  pathology  of  cirrhosis.  One  was  taken  from  the 
case  I  have  ah'eady  detailed  to  you  as  a  good  example  of  true 
cirrhosis  (Case  CIV.),  the  other  from  the  body  of  the  patient 
whose  case  I  am  about  to  mention  to  you  (Case  CXII.) . 

On  the  one  hand,  it  is  stated  that  in  cirrhosis  there  is  an 
increase  of  fibrous  tissue,  the  result  of  a  chronic  inflammatory 
process,  and  that  the  secreting  tissue  becomes  atrophied  from 
the  pressure  exerted  on  it  by  this  fibrous  tissue,  or  from  the 
conversion  of  the  gland-cells  into  fibre-cells  ;  while  on  the  other, 
it  is  contended  that  the  secreting  tissue  is  simply  atrophied, 
and  that  the  fibrous  tissue  is  not  absolutely,  though  relatively, 
increased.  The  former  view  is  the  one  advocated  by  Dr.  Budd 
in  his  work  on  Diseases  of  the  Liver, ^  and  the  latter  has  been  put 
forward  by  Dr.  Beale,^  and  has  been  adopted  hj  Sir  Thomas 
Watson  in  the  last  (fifth)  edition  of  his  classical  Lectures.  A 
third  class  of  pathologists,  among  whom  may  be  mentioned 
Forster,  believe  that  there  are  two  forms  of  granular  cirrhosis, 
one  in  which  the  fibrous  tissue  is  increased,  and  another  where 
it  is  not,  and  this  is  the  view  which  I  have  already  placed 
before  you  (see  pp.  275,  284).  Li  one  of  these  two  livers  the 
structure  is  extremely  dense,  and  the  fibrous  tissue  appears 
greatly  increased,  not  only  to  the  naked  eje,  but  on  microscopic 
examination  ;  -while  in  the  second  liver,  although  the  atrophy 
is  extreme,  so  that  the  weight  is  little  more  than  one-half  that 
of  the  first,  the  tissue  is  extremely  soft  and  friable,  and  there 
is  no  evidence  of  any  increase  of  the  fibrous  tissue,  either  to  the 
naked  eye,  or  on  microscopic  examination.  If  the  increased 
density  and  apparent  increase  of  fibrous  tissue  in  the  former  case 
be  due  merely  to  the  disappearance  of  a  portion  of  the  secreting 
tissue,  it  would  be  difficult  to  account  for  the  fact  that  in  the 
second  case,  although  the  atrophy  is  much  greater  than  in  the 
first,  the  consistence  of  the  organ  is  much  less  than  in  health 
and  there  is  no  apparent  increase  of  the  fibrous  tissue.  Both 
patients  exhibited  during  life  the  ordinary  phenomena  of  portal 
obstruction  met  with  in  cirrhosis ;  but  there  was  this  difference 
between  the  two,  that  the  patient  with  the  dense  fibrous  liver 
had  led  a  very  intemperate  life,  whereas  there  was  no  history 
of  intemperance  in  the  other  patient.  I  am  unable  to  throw 
any  light  on  the  etiology  of  the  disease  in  the  latter  case  ;  but 
the  absence  of  a  history  of  spirit-drinking,  which  is  almost 
universal  in  the  dense  fibrous  cirrhotic  liver,  is  worth  notiuo-. 

>  Third  ed.  p.  136.  2  Arcliiyes  of  Med.  vol.  i.  p.  12,^, 


304  CONTRACTIONS    OP   THE    LIVER.  lect.  viii. 

Case  CXII. — No  Ju'story  of  Sinrit-drinJdng — Sijmptoyns  of  Portal  Obstruc- 
tion— Soft,  atrophied,  granular  Liver — Simrious  Cirrhosis. 

Mary  0 ,  aged  68,  was  admitted  into  Middlesex  Hosp.  on  April 

1,  1867.  Her  laealtli  through  life  had,  on  the  whole,  been  good,  except 
that  at  the  age  of  45  she  had  been  confined  to  bed  for  six  weeks  with 
what  she  believed  to  have  been  I'henmatic  fever.  Since  then  she  had 
not  suffered  from  either  dyspnoea  or  palpitations  ;  her  habits  had  always 
been  temperate.  Her  present  illness  commenced  six  weeks  before  ad- 
mission with  vomiting-  and  purging.  Everything  she  swallowed  was 
rejected  within  ten  miuutes  ;  these  symptoms  continued,  and  after  three 
weeks  it  was  first  noticed  that  she  was  slightly  jaundiced,  and  about 
same  time  she  passed  a  good  deal  of  blood  from  vagina. 

On  admission,  patient  was  thin  and  very  weak  ;  she  had  a  well- 
marked  arcns  senilis,  and  decided  jaundice  of  skin,  conjunctivae,  and 
urine.  Pulse  108,  very  irregular;  visible  pulsation  of  many  of  arteries, 
which  felt  rigid  and  tortuous  ;  impulse  of  heart  strong  and  irregular, 
and  cardiac  dulness  slightly  increased,  but  no  bellows-murmur  audible. 
Respirations  28,  rather  laboured  ;  coarse  moist  rales  audible  at  bases 
of  both  lungs.  Abdomen  considerably  distended  and  tympanitic,  mea- 
surino-  33  in.  in  circumference  at  umbilicus,  but  no  distinct  indication 
of  fluid  in  peritoneum,  and  no  enlargement  of  subcutaneous  veins  of 
abdomen.  Considerable  oedema  of  both  lower  extremities,  but  urine 
contained  no  albumen.  Tongue  moist,  with  a  white  fur.  Motions  passed 
after  admission  were  dark  brown,  and  contained  abundance  of  bile. 

On  April  6  vomiting  and  diarrhoea  had  subsided,  but  there  was 
tolerably  clear  evidence  of  fluid  in  peritoneum,  and  slight  enlargement 
of  subcutaneous  abdominal  veins;  girth  at  umbilicus  35  in.,  but  it 
never  exceeded  this. 

From  this  date  patient  continued  in  a  very  low  state,  but  without 
any  increase  of  abdomen  or,  indeed,  change  of  any  sort,  until  April  30, 
when  vomiting  returned,  but  not  diarrhoea.  Patient  now  lost  all 
appetite ;  tongue  became  dry  and  brown ;  and  she  contin^^ed  to  sink 
until  death  on  May  13.  For  last  twenty-four  hours  of  life  she  was 
quite  unconscious. 

On  post-mortem  examination,  both  kidneys  contracted  and  granular, 
with  numerous  cysts  in  cortical  substance.  Considerable  hypertrophy 
of  left  ventricle  of  heart  and  atheroma  of  aorta,  but  valves  healthy. 
Lungs  slightly  emphysematous,  but  otherwise  normal.  Peritoneum 
contained  about  a  gallon  of  clear  straw-coloured  serum.  Intestines 
had  a  fleshy  appearance  (from  maceration)  and  there  was  slight  ecchy- 
mosis  in  mucous  membrane  of  caecum,  but  in  other  respects  they  were 
normal.  Spleen  of  natural  size  ;  with  exception  of  a  small  librous 
tumour,  uterus  was  healthy. 

Liver  extremely  small,  weighing  only  25*5  oz.  avoirtl.,  and 
measuring  7'75  in.  from  right  to  le^^t,  55  in.  antero-postcriorly  in  right 


LKCT.  VIII.  CHRONIC    ATROPHY.  305 

lobe,  and  475  in  leffc.  Its  capsule  was  not  at  all  tliickened,  and  was 
not  adherent ;  but  outer  surface  coarsely  nodulated  and  granular,  ex- 
actly as  in  cirrliosis  ;  margin  of  organ  all  round,  but  particularly  in 
front,  liad  a  winged  appearance,  from  total  disappearance  of  secreting 
tissue  between  capsule  on  upper  and  under  surfaces.  At  anterior 
margin  of  right  lobe  this  attenuated  rim  was  nearly  an  inch  in  width, 
and  only  about  a  third  of  an  inch  thick.  On  section  of  organ,  no 
evidence  of  any  increase  of  fibrous  tissue  ;  on  the  contrary,  consistence 
was  extremely  soft ;  cut-surface  presented  a  yellowish-brown  colour, 
and  a  coarsely  granular  appearance,  from  aggregation  of  lobules  into 
small  masses  ;  outline  of  individual  lobules  not  well  defined  ;  but  on 
microscopic  examination  secreting  cells  were  found  in  abundance, 
though  loaded  with  oil ;  no  leucin  nor  tyrosin.  The  attenuated  rim  pre- 
sented a  smooth  grey  appearance  on  section,  and  was  made  up  for  most 
part  of  fibrillated  tissue  and  vessels,  with  here  and  there  a  few  collapsed 
secreting  cells.  Projecting  from  this  rim  were  a  few  isolated  nodules 
of  yellowish-brown  hepatic  tissue,  about  size  of  peas. 

Case  CXIII.  is  an  instance  of  clironic  atrophy  of  the  liver 
arising  from  peri-hepatitis.  The  appearance  of  the  organ  was 
similar  to  what  is  often  seen  in  constitutional  syphilis,  although 
no  evidence  could  be  made  out  of  the  patient  having  had  syphilis. 
The  liver  was  very  small,  yet  there  was  no  indication  of  portal 
obstruction.  But  in  another  patient,  whose  body  I  dissected 
some  years  ago,  there  was  a  similar  condition  of  liver  with  great 
ascites  ;  the  spleen  weighed  27  oz,,  and  for  three  days  before 
death  there  had  been  severe  vomiting  and  purging,  with  much 
blood  in  the  vomited  matter  and  stools. 

Case  CXIII. — Chronic  Atrophy  of  the  Liver  from  Peri-hejyatitis — Siinple 
Ulcers  of  the  Sijmach. 

The  liver  and  stomach  which  I  now  show  you  were  removed  by  me 
from  the  body  of  a  woman,  aged  44,  who  died  in  Middlesex  hospital  some 
years  ago,  under  the  care  of  Dr.  Thompson.  She  was  admitted  on 
March  19,  and  died  on  April  15,  1861.  Six  months  before  admission 
she  began  to  get  thin,  and  to  suifer  from  nausea  and  loss  of  appetite, 
and  six  weeks  before  admission  pain  and  vomiting  after  food  came  on. 
The  symptoms  noted  while  the  patient  was  under  observation  were 
great  emaciation,  tenderness  in  region  of  liver,  dulness  of  which 
measured  less  than  2  in.  in  right  mammary  line,  pain  and  vomiting 
after  food,  and  constipation.  There  was  no  jaundice,  no  ascites,  and 
no  albumen  in  urine  ;  heart's  sounds  were  normal. 

After  death  liver  was  found  to  weigh  only  30^  oz.  ;  it  was  very 
small,  its  dimensions  being — extreme  length  9  in.,  ant.  post,  diameter 
6  in.,  greatest  thickness  2  in.     Capsule  was  thickened,  and  was  con- 

X 


306  CONTRACTIOXS    OF    THE    LIVER.  lkct.  yiu. 

nected  to  diaphragm  and  ribs  by  numerous  fiue  long  fibrous  bands. 
Its  outer  surface  was  marked  by  extensive  cicatrix-like  depressions, 
and  scattered  through  its  substance  were  many  firm  fibroid  gummata, 
about  size  of  a  pea,  composed  of  fibrillated  tissiie  with  oily  and  granuhir 
matter.  Glandular  tissue  which  remained  appeared  healthy.  Pyloric 
end  of  stomach  Avas  thickened  and  narrowed  from  what  appeared  to 
be  cicatrices  of  former  ulcers.  Two  inches  from  pylorus  was  an  open 
ulcer,  size  of  a  threepenny-piece.  Spleen  not  enlarged  ;  commencing 
waxy  disease  of  kidneys.  A  few  small  patches  of  recent  lobular  pneu- 
monia in  both  lungs  ;  base  of  right  lung  connected  to  diaphragm  by 
finn  adhesions.  No  cicatrices  could  be  discovered  on  labia,  in  groins, 
or  over  tibiae. 

In  Case  CXIV.  the  atrophy  of  the  liver  appeared  to  be 
secondary  to  disease  in  the  chest.' 

Case  CXIV. — Bronchitis  and  Dilated  Bronchi — Disease  of  Aortic 
Valves — Contracted  Liver — Great  Ascites. 

The  liver  which  you  see  here  is  not  much  more  than  one-half  of 
normal  size;  it  weighed  only  33  oz.  Its  outer  surface  is  finely 
granular,  being  marked  by  numerous  small  depressions  corresponding 
to  the  centre  of  the  lobules.  The  capsule  at  many  places  is  much 
thickened,  and  was  adherent  to  the  surrounding  parts,  and  the  fibi-ous 
tissue  in  the  interior  of  the  organ  is  increased.  Before  immersion  in 
spirit,  the  surface  on  section  presented  a  nutmeg  appearance. 

This  liver  was  taken  from  the  body  of  a  man  aged  40,  who  was  a 
patient  in  this  (Middlesex)  hospital  from  June  27  to  July  16, 1860,  and 
again  from  November  13,  1800,  until  his  death  on  January  5,  1861. 
He  had  been  in  habit  of  drinking  spirits,  but  not  in  excess.  His  illness 
commenced  about  a  year  before  death  with  cough,  dyspnoea,  and  other 
signs  of  bronchitis.  After  three  months  his  legs  began  to  swell,  and 
subsequently  his  abdomen,  but  at  time  of  his  first  admission  anasarca 
of  legs  was  comparatively  slight,  although  abdomeii  was  enormously 
distended  from  ascites.  The  patient  suffered  much  from  pain  below 
right  ribs  ;  hepatic  dulness  was  diminished  ;  thei"c  was  no  albumen  in 
urine,  but  there  was  a  diastolic  blowing  murmur  at  base  of  lioart. 

Bronchial  tubes  after  death  were  found  to  be  much  thickened  and 
dilated,  and  pulmonary  tissue  at  many  j)laces  was  in  a  state  of  fibroid 
degeneration.  Right  lung  was  inseparably  adherent  to  wall  of  chest. 
Right  cavities  of  heart  dilated  ;  aortic  valves  Avere  incompetent ;  two 
of  flaps  were  united  into  one,  and  in  all  of  them  there  was  a  considerable 
amount  of  atheroma. 

The  followin^j^  case  was  published  by  me  some  years  ago,  in 
the  Patholoj^ical  Transactions,    vol.  vii.  p.  238.      It  was  an 

'  See  also  tlie  case  of  Mary  T ,  related  in  Lecture  XII. 


i.BCT.  viii.  CHRONIC    ATEOPHT.  307 

interesting  example  of  chronic  atrophy  of  the  liver,  in  conjunc- 
tion with  great  enlargement  of  the  spleen  and  leuktemia. 
Although  the  organ  was  described  at  the  time  as  'in  an  advanced 
stage  of  cirrhosis,'  the  firm  adhesions  of  the  liver,  omentum, 
and  spleen,  the  thickened  capsule  of  the  spleen  and  the  oblite- 
ration of  the  cystic  duct,  all  pointed  to  chronic  peritonitis  aS 
the  probable  cause  of  the  atrophy.  There  was  no  history  of 
spirit-drinking.  The  remarkable  circumstance,  however,  which 
induces  me  to  mention  the  case  is  that  on  four  different  occa- 
sions large  quantities  of  fluid  were  abstracted  from  the  abdomen 
by  paracentesis,  and  that  the  patient  lived  for  nearly  two  years 
afterwards  without  any  reaccumulation. 

Case  CXV. — Chronic  Atrophy  of  Liver  and  Ascites — Paracentesis  — 
No  Accumulation  after  fourth  Tapping — Enlarged  Spleen  and  Leulcce- 
mia — Death  from  Ulceration  of  Mouth  and  Necrosis  of  Jaw  and 
Vertehrce. 

The  patient  was  a  female,  who  had  been  born  and  had  always  re- 
sided in  London.  She  had  been  very  temperate,  but  always  very  deli-.. 
cate.  The  catamenia  had  not  appeared  until  she  was  twenty,  and  al- 
though married  for  eleven  years,  slae  never  had  any  children  or  mis- 
carriages. In  1850,  Avhen  31  years  of  age,  she  first  noticed  a  swelling- 
below  right  ribs  ;  but  this  did  not  give  her  much  inconvenience  till  end 
of  1853,  when  whole  abdomen  began  to  enlarge,  and  on  April  12, 
1854,  she  was  admitted  into  Hospital  for  Women  in  Soho  Square- 
under  Dr.  Tanner. 

She  was  then  suffering  from  symptoms  of  diseased  liver  and  ascites j. 
and  abdomen  measured  43f  in.  in  circumference,  and  18^  in.  from 
ensiform  cartilage  to  pubes.  During  stay  in  hospital  she  was  treated 
with  iodide  of  potassium,  mercurial  ointments  and  purgatives,  aad 
abdomen  was  tapped  four  times.  On  April  17,  356  fluid  oz.  of 
clear  fluid  were  drawn  off;  on  May  19,  400 ;  on  June  16,  431  ;  and  oe 
July  7,  404 ;  altogether  1,591  fluid  oz.  After  last  operation,  fluid 
did  not  collect  again,  and  patient  left  hospital  greatly  improved  in 
health,  and  with  abdomen  of  natural  size. 

There  was  no  return  of  ascites  ;  but  some  naonths  afterv^^ards  she 
began  to  suffer  from  ulceration  of  mouth  and  throat,  producing  a  very 
fetid  discharge.  Several  of  her  teeth  came  out,,  and  in  October  1855  a 
portion  of  alveolar  process  of  lower  jaw  exfoliated.  She  had  alsa 
several  severe  attacks  of  epistaxis,  and  bleeding  from  gums.  On  March 
12,  1856,  she  came  under  my  care.  She  was  then  extremely  weak  and 
confined  to  bed.  There  was  extensive  ulceration  of  fauces  and  along 
margin  of  gums,  but  voice  was  natural.  She  stated  that  she  had  never 
suffered  from  syphilis,  nor  taken  mercury  internally.     Whole  of  left 

X  2 


308 


CONTRACTIONS    OF    THE    LIVER. 


LECT.    VIII. 


side  of  abdomen  was  filled  by  a  solid  tumour,  extending  forwards  to 
within  2^  in.  of  umbilicus,  but  no  ascites  ;  hepatic  dulness  diminished, 
not  exceeding  2^  in.  in  right  mammary  line. 

The  ulceration  of  mouth  rapidly  extended.  More  teeth  and  pieces 
of  bone  came  away  from  jaw  ;  body  of  one  of  cervical  vertebra3  became 
exposed  ;  and  dysphagia  was  so  great  that  at  last  even  fluids  Avere  re- 
jected by  nares. 

After  death,  less  than  a  pint  of  clear  serous  fluid  was  found  in  ab- 
dominal cavity,  and  omentum  was  firmly  adherent  to  abdominal  wall. 
Liver  very  small,  and  weighed  only  35  oz.  Its  outer  surface  firmly 
adherent  to  surrounding  parts,  and  organ  was  described  at  time  as  '  in 
an  advanced  stage  of  cirrhosis.'     There  was  bile  in  gall-ducts  and  in- 


I'iff.  28. 


Minute   crystalline   masses  of  carbonate  of  lime  from  gall-bladder  in  Caso 
CXV.,  magnified  180  diameters. 


testines,  but  gall-bladder  contained  none  ;  cystic  duct  obliterated,  and 
vessels  and  duct  in  portal  fissure  passed  through  a  quantity  of  firm 
fibrous  tissue.  Gall-bladder  collapsed  ;  its  lining  membrane  perfectly 
white  and  encrusted  with  small  fragments  of  earthy  matter,  some  of 
which  were  finnly  adherent ;  this  consisted  mainly  of  carbonate  of  lime ; 
it  effervesced  with  acids,  and  microscopic  examination  showed  it  tc 


fi-  *? 


W~<\     /  ••-/-'.^■■•"h*»l'->  A  CD/- V<A»«J 


V\\i,.  29.     Microscopic  appearances  of  the  blood  in  Case  CXV.,  magnified  400  diameters. 

consist  of  rounded  crystalline  particles,  varying  in  size  from  -^J,,-,  of  an 
inch  to  an  almost  infinite  degree  of  minuteness ;  some  of  them  seemed 
to  be  made  up  of  radiating  acicular  crvstals  cohering  in  the  ccntie 
(fig.  28). 


LRCT.  viii.  CHRONIC    ATROPHY.  309 

Spleen  weighed  6b^  oz.  and  measured  llj  in.  by  4  in.  Its  capsule 
was  mucli  tliickened,  indurated,  and  adherent  to  surrounding  parts ; 
splenic  tissue  firm  and  of  a  reddish-brown  colour,  mottled  with 
numerous  lighter  specks  like  sago-grains.  The  blood  from  all  parts  of 
body  exhibited  appearances  described  by  Virchow  in  cases  of  leukae- 
mia. There  was  a  great  increase  of  colourless  corpuscles,  which,  on 
addition  of  weak  acetic  acid,  presented  a  single,  double,  treble,  or  quad- 
ruple nucleus.  Some  of  these  nuclei  were  crescentic,  and  many  of  them 
appeared  depressed  in  centre  like  small  red  corpuscles.  Some  of  celJs, 
in  addition  to  nuclei,  contained  a  few  minute  oil-globules,  and  there  was 
also  a  considerable  qnantity  of  free  granular  matter  and  oil-globules. 
The  red  corpuscles  showed  no  unusual  tendency  to  collect  in  rolls,  as  in 
some  cases  of  leukaemia  (see  fig,  29). 

Heart,  lungs,  and  kidneys  healthy. 


3IO  JAUNDICE. 


LECTURE    IX. 
J  A  UNDICE. 

DKFINITION — RECOGNITION    OF  CAUSES— SPt'ElOIS    JAUNDICE— PHENOJIENA  OF  JAUNDICE  : 
1.  LOCALITY  &C.  ;    2.  SECRETIONS  ;   3.  BITTER  TASTE  ;    4.  DERANGEMENTS  OF  DIGESTION  ; 

o.     pruritus;     6.     cutaneous     eruptions;     7-     temperature;     8.    pulse;    9. 

IITEMORRHAGES  ;      10.      GENERAL      DEBILITY     AND      ANAEMIA;      11.       YELLOW      TISION  ; 
12.    CEREBRAL    SYMPTOMS THEORY    OF    JAUNDICE. 

Gentlemen, — Jaundice  may  be  defined  as  a  yellowness  of  the 
integuments  and  conjunctiva),  and  of  the  tissues  and  secretions 
generally,  from  impregnation  with  bile-pigment.  The  word 
jaundice  in  fact  is  derived  from  the  French  jaune,  yellow.  The 
technical  name  icterus  is  less  appropriate,  being  the  Greek  word 
for  the  golden  thrush,  a  bird  with  golden  jjlumage,  the  sight  of 
which  by  a  jaundiced  person  was  believed  by  the  ancients  to  be 
death  to  the  bird,  but  recovery  to  the  patient. 

Few  morbid  symptoms  are  due  to  such  multifarious  causes 
as  jaundice,  and  there  are  none  as  to  which  it  is  more  difficult  or 
important  to  determine  the  cause.  It  is  too  much  the  custom 
for  even  medical  men  to  be  satisfied  with  the  fact  that  a  patient 
has  got  'jaundice,'  and  to  administer  remedies  which  are  sup- 
posed to  exercise  some  special  action  on  the  liver,  without 
taking  much  trouble  to  investigate  further  ;  and  yet  the  prognosis 
and  the  whole  treatment  of  the  case  ought  to  depend,  not  on 
the  jaundice,  but  on  its  cause.  The  difficulty  of  the  subject  is 
further  increased  by  the  fact,  that  even  those  who  have  devoted 
most  attention  to  the  subject  are  not  at  one  as  to  the  mode  of 
production  of  jaundice  in  many  cases.  I  shall  endeavour  in 
these  lectures  to  explain  to  you  the  various  causes  of  jaundice, 
the  mode  in  which  they  operate,  and  the  means  of  distinguish- 
ing them.  But  in  the  first  place  it  will  be  well  that  I  should 
refer  to  instances  of  what  may  be  called  i^purious  jaundice,  and 
describe  to  you  certain  phenomena  connected  with  jaundice 
irrespectively  of  its  cause. 


SPURIOUS    JAUNDICE.  3  I  I 


SPURIOUS    JAUNDICE. 


lu  the  first  place,  then,  you  must  be  quite  certain  that  you 
have  to  deal  with  jaundice,  before  proceedinc^  to  investigate  its 
cause.  As  a  rule  there  is  no  great  difficulty  in  the  diagnosis  ; 
you  have  only  to  look  at  the  patient  to  know  what  is  the  matter 
with  him.  There  are,  however,  certain  conditions  which  are  apt 
to  be  mistaken  for  the  slighter  forms  of  jaundice,  and  it  is  very 
necessary  that  you  should  keep  in  remembrance  these  sources 
of  error. 

1.  First,  there  is  the  greenish-yellow  colour  of  countenance 
observed  in  the  anaemic  state  known  as  chlorosis,  which  is  due 
to  a  morbid  state  of  the  blood.    This  is  distinguished  by — 

a.  A  pearly  whiteness  of  the  conjunctivse  and  pallor  of  the 
lips  and  tongue. 

h.  Other  symptoms  of  anaemia,  such  as  a  feeble  pulse,  a  venous 
hum  in  the  neck,  and  a  systolic  bellows-murmur  at  the  base  of 
the  heart  without  any  other  indication  of  disease  of  the  heart. 

c.  In  females,  amenorrhcea,  or  some  other  indication  of 
uterine  derangement. 

d.  Absence  of  bile-pigment  from  the  urine. 

2.  There  is  a  peculiar  greyish-yellow  or  lemon-coloured 
waxen  a,ppearance  of  skin  characteristic  of  organic  visceral 
disease,  and  especially  of  cancer.  This  is  distinguished  from 
jaundice  by — 

a.  The  absence  of  any  yellow  tint  of  the  conjunctivse. 
h.  The  absence  of  bile-pigment  from  the  urine, 
c.  The  presence  of  other  symptoms  or  local  signs  of  visceral 
disease,  or,  in  the  case  of  cancer,  of  the  cancerous  cachexia. 

3.  A  dusky  yellowish  colour  of  the  surface  is  not  unfre- 
quently  developed  in  persons  who  have  sufPered  long  or  often 
from  malarious  fevers,  and  sometimes  also  in  those  whose 
systems  have  been  poisoned  by  lead,  or  who  are  the  subjects  of 
granular  kidneys.    This  condition  is  to  be  recognised  by  — 

a.  The  absence  of  any  yellow  tint  of  the  conjunctivse. 
h.  The  absence  of  bile-pigment  from  the  urine. 

c.  The  fact  of  the  individual  having  suffered  from  malarious 
fevers,  or  lived  in  a  malarious  country. 

d.  Exposure  to  the  poison  of  lead,  with  a  blue  line  along  the 
margin  of  the  gums,  or  a  history  of  lead-colic  or  palsy. 

e.  The  other  symptoms  of  granular  kidney,  viz. : — copious 


312  JAUNDICE.  i.FXT.  'X. 

urine  of  low  specific  gravity,  containing  from  time  to  time  a 
small  quantity  of  albumen,  hypertrophy  of  the  left  ventricle  of 
the  heart  independent  of  valvular  disease,  visible  arteries,  &c. 

4.  A  yellowish  colour  of  the  conjunctivse  may  be  due  to  sub- 
conjunctival fat.     This  is  distinguished  by — 

a.  The  yellow  tint  not  being  uniform. 

h.  The  absence  of  jaundice  of  the  skin,  or  of  bile  pigment  in 
the  urine. 

5.  In  a  large  number  of  the  cases  of  so-called  jaundice  of 
new-born  children  [icterns  neonatorum),  the  yellow  colour  which 
appears  on  the  third  or  fourth  day  after  birth  is  not  due  to 
jaundice,  but  is  merely  the  result  of  changes  in  the  blood  in  the 
over-congested  skin,  the  vivid  redness  of  the  new-born  babe 
fading  as  bi-uises  fade,  through  shades  of  yellow  into  the 
genuine  flesh  colour.^  Young  infants,  however,  are  liable  to 
real  jaundice,  to  which  I  shall  refer  hereafter.  The  spurious 
affection  differs  from  this  in — 

a.  The  conjunctivae  being  of  the  natural  colour. 

h.  The  urine  being  free  from  bile-pigment. 

c.  The  gradual  fading  of  the  yellow  colour  of  the  skin  after 
a  few  days. 

The  child  being  quite  well,  and  the  bowels  acting  properly. 

6.  The  bronzing  of  Addison's  disease  is  not  likely  to  be 
mistaken  for  jaundice.     It  differs — 

a.  In  the  browner  or  more  dusky  character  of  the  discolora- 
tion, and  in  the  fact  of  its  being  darker  at  certain  parts,  such 
as  the  face,  neck,  hands,  areolae  of  the  nipples,  axillae,  penis, 
scrotum,  &c. 

h.  In  the  presence  of  other  symptoms  of  Addison's  disease, 
and  particularly  of  extreme  anaemia  and  vomiting. 

c.  In  the  whiteness  of  the  conjunctivae. 

d.  In  the  absence  of  bile-pigment  from  the  urine. 

7.  Persons  who  have  been  much  in  hot  climates  or  exposed 
to  the  sun  may  have  a  permanent  bronzed  appearance  of  the 
face,  which  is  distinguished  from  jaundice  by — 

a.  The  skin  of  the  chest  and  other  parts  of  the  body  having 
a  natural  tint. 

b.  Whiteness  of  the  conjunctivae. 

c.  Absence  of  bile-pigment  from  the  urine. 

8.  Other  pigments  in  the  urine  may  give  to  this  secretion  a 
colour  which  may  be  mistaken  for  that  of  bile-pigment,  such, 

»  See  West,  Dis.  of  Children,  fylh  ed.  ISC'),  p.  GOl. 


■LECT.  IX.  PHENOMEIfA    AND    SYMPTOMS.  313 

for  instance,  as  those  which  are  common  in  diseases  interfering 
with  the  respiratory  functions.  But  bile-pigment  can  always 
be  recognised  by  the  urine  staining  the  linen  yellow,  and  still 
better  by  testing  with  nitric  acid.  If  yon  ponr  a  small  qna.ntity 
of  urine  containing  bile  on  a  white  plate,  or  on  a  sheet  of 
writing-paper,  and  carefully  allow  a  drop  or  two  of  nitric  acid 
to  fall  upon  it,  an  immediate  play  of  colours  will  be  produced 
around  the  spot  where  the  acid  falls,  passing  from  brown 
through  green,  blue,  violet,  and  red,  into  a  dirty  yellow.^ 

9.  Lastly,  those  of  you  who  may  enter  the  public  services 
ought  to  remember  that  jaundice  has  been  successfully  feigned 
by  soldiers  and  sailors  desirous  of  obtaining  a  discharge.  The 
yellow  colour  of  the  slrin  has  been  simulated  by  painting  it  with 
infusions  of  saffron,  turmeric,  rhubarb,  broom-flowers,  or  soot ; 
while  the  colour  of  the  urine  has  been  heightened  by  taking 
rhubarb  or  santonin.^  But  in  feigned  jaundice  you  will 
find — 

a.  That  the  conjunctivae  are  white. 

h.  That  bile-pigment  cannot  be  detected  in  the  urine  by  the 
nitric-acid  test;  and, 

c.  That  soap  and  water,  or  better  still  a  weak  solution  of 
chloride  of  lime  will  remove  the  yellow  colour  from  the  skin. 

d.  If  the  urine  be  coloured  by  the  use  of  santonin  or 
rhubarb,  it  will  be  rendered  blood-red  by  the  caustic  alkalies  or 
their  carbonates. 

I  will  now  call  your  attention  to — 

CEETAIIf    PHENOMENA    AND    CONCURRENT    SYMPTOMS    OP   JAUNDICE 
IRRESPECTIVE    OP    ITS    CAUSE. 

1.  The  Locality  and  Intensity  of  the  jaundice.  Most  of  the 
organs  and  tissues  of  the  body  become  impregnated  with  bile- 
pigment.  This  first  accumulates  in  the  blood,  and  the  jaundiced 
tint  penetrates  almost  every  part  of  the  body  that  is  permeated 

'  According  to  Frerichs  this  reaction  may  fail  in  consequence  of  the  bile-pigment 
in  the  u-ine  having  undergone  some  transformation,  in  cases  where  the  other  sym- 
ptoms of  jaundice  are  undoubted.  When  this  is  the  case,  the  urine  is  at  one  time  of 
a  broAvn  or  brownish-red  colour,  and  becomes  red  on  the  addition  of  nitric  acid  ;  at 
another  time  it  is  of  a  deep  red,  which  is  converted  by  nitric  acid  into  a  dark  bluish- 
red.  (Dis.  of  Liver,  Syd.  Soc.  Ed.  i.  100.)  I  have  made  a  similar  observation  in 
rare  cases  where  jaundice  has  resulted  from  a  blood-poison,  and  I  have  frequently 
found  the  urine  to  present  these  characters  where  there  has  been  no  jaundice,  b^^t 
obvious  derangement  of  fvmction,  or  alteration  of  structure,  of  the  liver, 

-  Gavin,  on  Feigned  and  Fictitious  Diseases,  1843,  p.  389. 


314  JAUNDICE.  lECT.  IX. 

by  blood — even  the  brain,  the  bones,  and  the  foetus  in  utero. 
The  mucous  membranes,  however,  are  but  slightly  coloured, 
although  the  tongue  is  often  distinctly  yellow.  The  tissue  of 
the  brain  and  spinal  cord  also  does  not  become  impregnated 
with  bile-pigment ;  the  yellow  colour  which  they  present  on 
section  being  due  to  the  exudation  of  jaundiced  serum  from 
the  cut  ends  of  the  vessels.  Lastly,  in  cases  of  even  intense 
jaundice,  it  is  remarkable,  from  whab  we  know  of  the  laws  of 
osmotic  diifusion,  that  the  humors  of  the  eye  and  the  crystalline 
lens  remain  free  from  any  trace  of  bile-pigment :  by  some 
observers  they  have  been  found  to  present  a  yellow  tinge,  but 
the  occurrence  is  certainly  exceptional.^ 

The  intensity  of  the  jaundice  varies  in  the  different  tissues 
of  the  body.  When  the  jaundice  depends  on  obstruction  of  the 
common  bile-duct,  the  liver  itself  is  the  organ  that  is  most 
deeply  coloured ;  it  often  presents  a  deep  olive  hue.  But  when 
there  is  no  impediment  to  the  flow  of  bile  into  the  bowel,  the 
liver  may  not  be  more  jaundiced  than  other  parts. 

Next  to  the  liver,  the  skin  is  the  tissue  which  becomes  most 
jaundiced  ;  but  before  it  becomes  affected  a  yellow  tint  is  usually 
observed  in  the  conjunctivse.  There  must,  so  to  speak,  be  a 
certain  concentration  of  bile-pigment  to  produce  a  yellow  colour 
of  the  skin  ;  in  the  slighter  and  more  temporary  cases  the  con- 
junctivae only  may  be  affected.  Although  it  has  been  shown 
by  experiment  upon  animals,  that  after  the  passage  of  bile 
through  the  ducts  has  been  arrested  several  days  may  elapse 
before  the  conjunctivse  become  jaundiced,  yet  in  the  human 
subject  twenty-four  hours  usually  suffice  for  both  skin  and  con- 
junctiva3  to  become  yellow. 

The  colour  of  the  skin  varies  from  a  pale  sulphur  or  lemon - 
yellow,  through  a  citron-yellow,  to  a  deep  olive  or  bronzed  hue. 
The  tint  varies  according  to  the  cause  and  the  duration  of  the 
disease.  When  the  cause  is  obstruction  of  the  bile-duct  it  is 
light  at  first,  and  increases  in  depth  the  longer  the  disease 
lasts.  When  the  jaundice  is  independent  of  obstruction  to  the 
flow  of  bile,  the  colour  is  rarely  very  deep  at  any  time,  and  yet 
these  are  often  the  most  serious  cases.  Instances  occur  where 
the  jaundice  is  of  a  greenish  or  almost  black  hue,  owing  to  the 
bile-pigment  which  is  absorbed  being  vitiated  and  dark,  or  to 
the  visage  being  already  livid  from  imperfect  arterialisation  of 
the  blood,  the  green  colour  being  a  result  of  the  mingling  of 

'  Sue  Moxon,  Laucot,  1873,  i.  130. 


LECT.  IX.  PHENOMENA    AND    SYMPTOMS.  315 

the  blueness  of  lividity  with  the  natural  yellowness  of  jaundice  ; 
in  either  case  the  prognosis  is  unfavourable.  The  colour  also 
varies  with  the  age,  the  natural  complexion,  and  the  amount  of 
fat  in  the  individual.  It  is  deeper  in  the  old,  the  wrinkled,  and 
the  dark-complexioned,  than  in  young  persons  of  fair  complexion, 
and  with  plenty  of  fat.  Again,  in  the  same  person,  without 
any  change  in  the  cause,  the  intensity  of  the  colour  may  vary 
from  day  to  day,  according  to  the  diet,  the  amount  of  bile 
secreted  by  the  liver  and  the  rapidity  with  which  it  is  trans- 
formed in  the  blood,  and  the  activity  of  the  bowels  and  kidneys. 
Lastly,  it  is  important  to  remember  in  reference  to  treatment, 
that  the  colour  often  remains  in  the  skin  for  some  time  after  the 
cause  of  the  jaundice  has  been  removed,  and  that  then  its 
departure  may  be  expedited  by  diaphoretics  and  warm-baths. 

2.  The  Secretions  are  tinged  with  bile-pigment,  but  some 
much  more  so  than  others.  This  is  notably  the  case  with  the 
urine,  by  which  the  greater  part  of  the  bile-pigment  in  jaundice 
is  eliminated  from  the  body,  and  which  acquires  a  saffron- 
yellow,  greenish-brown,  or  brownish-black  hue,  a.ccording  to 
the  amount  of  pigment  which  it  contains.  The  urine  usually 
becomes  yellow  before  there  is  any  yellow  tint  of  the  skin,  or 
even  of  the  conjunctivae,  and  it  may  happen,  when  the  cause 
of  the  jaundice  is  temporary,  that  the  whole  of  the  pigment  is 
eliminated  by  the  urine,  without  any  jaundice  appearing  in  the 
skin.  On  the  other  hand,  when  once  the  skin  becomes  yellow, 
it  may  remain  so  for  some  time  after  its  cause  has  been  removed, 
and  after  bile-pigment  has  quite  or  nearly  disappeared  from  the 
urine.  The  bile-acids  have  also  been  found  in  the  urine  of 
some  cases  of  jaundice,  but  in  cases  of  long  standing  they 
usually  disappear. 

The  precipitates  which  fall  from  jaundiced  urine  often  con- 
tain angular  granules  of  brownish-black  pigment,  as  well  as 
renal  epithelium  and  casts  of  the  renal  tubes.  Tube-casts, 
without  albuminuria,  according  to  Dr.  James  Finlayson,^  are 
extremely  common,  and  appear  to  be  due  to  the  jaundice  itself, 
and  not  to  the  special  diseases  producing  it. 

Other  secretions  in  cases  of  jaundice  contain  bile-pigment, 
as  well  as  the  urine. 

The  cutaneous  glands  usually  eliminate  the  pigment,  and 
sometimes  in  such  quantity  as  to  stain  the  linen  yellow,  but  the 

'  Brit,  and  For.  Med.  Chir.  Eev.  Jan.  1876. 


3l6  JAUNDICE.  i.ECT.  IX. 

amount  discliarged  in  tliis  way  is  small  wlien  compared  with 
that  which  escapes  through  the  kidueys. 

Dr.  Bright  ^  and  others  have  recorded  instances  where  the 
secretion  of  the  mammary  glands  has  been  found  tinged  with 
bile-pigment,  but  cases  of  this  sort  are  not  common ;  while 
Heberden  knew  a  woman  with  deep  jaundice  suckle  her  infant 
for  six  weeks  without  imparting  to  it  a  yellow  colour,  or  injur- 
ing its  health.       Still  rarer  instances  have  been  noticed  where 
the  saliva,  or  the  tears,  have  been  similarly  affected.     It  is  not 
a  little  remarkable,  however,  that,  notwithstanding  statements 
of  a  contrary  natui^e  which  have  been  made  by  Foiu'croy,'^  and 
Dr.   Osborne  of    Dublin,^  bile-pigment   is   not  eliminated  in 
cases  of  jaundice  by  the  mucous  membrane  of  the  respiratory 
passages,  or  of  the  digestive  tube.      This  is  a  matter  of  some 
practical  importance,  for,  were  the  fact  otherwise,  the  stools 
might  contain  bile-pigment  even  Avhen  there  was  complete  ob- 
struction of  the  gall-duct.      But  when  either  of  these  mucous 
membranes  is  inflamed  and  separates  an  albuminous  or  fibrinous 
exudation  from  the  blood,  the  altered  secretions  may  contain 
bile-pigment.      Thus  when  pneumonia  coexists  with  jaundice, 
there  is  often  bile-pigment  in  the  sputa,  which  may  be  distin- 
guished by  the  nitric  acid  test  from  the  greenish  or  yellow  colour 
often  presented  by  pneumonic  sputa  owing  to  changes  in  the 
blood-pigment  independent  of  bile.     Indeed,  in  cases  of  jaun- 
dice, bile-pigment  may  be  detected  in  inflammatory  exudations, 
as  in  the  serum  of  a  blister,  before  it  appears  in  either  the  skin 
or  even  in  the  urine.     It  is  probable  that  those  rare  cases  where 
the  saliva  has  been  noticed  to  be  yellow  admit  of  a  similar 
explanation.      In  the  cases  recorded  by  Huxham''  and  Budd,'^ 
which    have   been    so  often  referred  to,  there  was  mercurial 
salivation,  in  which  condition  the  saliva  is  not  normal,  but 
contains  much  albumen. 

3.  A  hitter  taste  is  not  unfrequently  complained  of  by  persons 
who  are  the  subjects  of  jaundice.  Sometimes  this  appears  to  be 
due  to  eructations  from  the  stomach  of  bilious  matter,  but 
when  the  bile-duct  is  obstructed  this  of  course  is  impossible. 
It  then  probably  denotes  the  presence  in  the  blood  of  the  biliary 
acids,  for  bile-pigment  is  tasteless,  while  tanrocholic  acid  is 
int<3nsely  bitter.     That  the  bitter  taste  is  not  due  to  the  presence 


'  Guy's  Hosp.  Rep.  Lst  Ser.  i.  G'23.     Sec  also  I5u(kl,  Dis.  of  Liver,  Srd  ed.  p.  470 
«  Frerichs.  op.  cit.  i.  103.  '  Dul.lin  Journal  of  Moil.  Feb.  18.33. 

*  Op.  Physico-medica,  torn.  iii.  p.  12,     *  Budd,  op.  cit.  p.  469. 


J 


LECT.  IX.  PHENOMENA    AND    SYMPTOMS.  31/ 

of  bile-pigment  in  tlie  blood  is  shown  by  the  fact,  that  a  similar 
taste  is  constantly  complained  of  by  persons  who  have  hepatic 
derangement  without  jaundice. 

4.  Derangements  of  Digestion. — The  chief  derangements  of 
digestion  resulting  from  the  absence  of  bile  from  the  intestines 
are  flatulence,  constipation,  and  an  altered  character  of  the 
motions.  Bile  has  powerful  antiseptic  properties,  and  conse- 
quently, when  it  is  absent,  the  intestinal  contents  undergo, 
decomposition,  gases  accumulate  in  the  bowels  and  cause 
tympanitic  distension  of  the  abdomen,  and  the  motions  acquire 
a  putrid  odour.  Owing  to  the  absence  of  bile-pigment  also  the 
motions  present  a  pale  drab  or  clay  colour.  Bile  appears  also 
to  be  the  natural  stimulant  of  the  peristaltic  action  of  the  gut, 
and  consequently  when  the  supply  is  cut  off  the  bowels  are 
usually  constipated.  On  the  other  hand,  the  putrid  fseces 
sometimes  irritate  the  bowel  and  excite  diarrhoea.  The  pu- 
tridity and  paleness  of  the  motions  and  the  constipation  are 
confined  to  those  cases  where  there  is  complete  obstruction  of 
the  ducts.  When  the  ducts  are  free,  or  where  the  obstruction 
is  incomplete,  and  when  bile  still  enters  the  bowel,  the  motions 
may  be  but  little  altered  and  may  be  voided  regularly. 

When  bile  does  not  enter  the  bowel,  the  digestion  of  fat  is 
interfered  with.     Jaundiced  patients  dislike  fat  and  do  not  assi- 
milate it,  the  fatty  matter  in  the  ingesta  being  discharged  with 
the  fseces.     This  is  still  more  remarkably  the  case  when  the  pan- 
creatic secretion  is  also  prevented  entering  the  bowel,  but  it  was 
long  since  shown  by  Drs.  Bright  and  Owen  Rees  ^  that  in  most 
cases  of  very  obstinate  jaundice,  when  there  is  complete  obstruc- 
tion of  the  bile-duct,  an  unusual  quantity  of  fat  may  be  detected 
in  the  stools.     In  protracted  obstruction  of  the  bile-duct  there  is 
also,  as  has  been  shown  by  Dr.  Wickham  Legg  ^  and  von  Wittich, 
a  complete  cessation  of  the  glycogenic  function  of  the  liver, 
which  would  account  in  part  for  the  emaciation  which  takes  place. 
In  all  cases,  therefore,  of  jaundice  from  obstruction  of  the  duct, 
the  nutrition  of  the  body  suffers :  the  emaciation  may  be  slow, 
but  it  is  usually  progressive,  until  the  fat  disappears  from  the 
body,  and  then  the  weight  of  the  body  may  remain  stationary. 
Cases,  it  is  true,  have  been  recorded  where  patients  have  lived  for 
several  years  with  jaundice,  and  where  there  has  been  compara- 
tively little  wasting,  but  these  cases  are  exceptional. 

'  Guy's  Eosp.  Reports  1836,  Ser.  1,  vol.  i.  p.  610. 

2  Barlh.  Hosp.  Eep.  vol.  ix.  1873,  and  Erit.  Med.  Journ.  Aug.  26,  1876. 


3 1 8  JAUNDICE.  LKCT.  IX. 

5.  Fniritus  wifcliout  any  ernption  on  the  skin  is  often  a 
very  obstinate  and  distressing  symptom  in  janndice.  It  some- 
times precedes  the  jaundice,  and  it  is  a  common  spnptom  of 
hepatic  disorder  where  there  is  no  jaundice.  In  two  cases  the 
late  Dr.  Graves  observed  this  itchiness  precede  the  jaundice — in 
one  for  ten  days,  and  in  the  other  for  two  months — and  cease 
as  soon  as  the  jaundice  appeared.  More  commonly  it  is  first 
noticed  at  the  commencement  of  the  jaundice  (Case  CXXVII.) ; 
sometimes  it  comes  and  goes,  and  at  others  it  persists  as  long  as 
the  jaundice  lasts,  being  usually  worse  at  night  and  preventing 
sleep.  You  have  now  an  opportunity  of  witnessing  the  great 
distress  which  this  symptom  may  occasion  in  the  case  of  William 

M (Case  CXXVII.).      This  man  has  had  jaundice  from 

obstruction  of  the  common  bile-duct  for  many  months,  and 
throughout  his  suffered  from  intense  itchiness,  which,  not- 
withstanding opium,  subcutaneous  injections  of  morphia,  and 
anodynes  of  every  sort,  has  caused  him  wretched  nights.  The 
bicarbonate  of  potash  is  the  only  remedy  that  has  appeared  to 
give  relief.  Pruritus  is  rarely  observed  in  janndice  independent 
of  obstruction  of  the  bile-duct.  It  is  not  known  on  what  in- 
gredient of  the  bile  this  itchiness  depends,  but  the  facts  of  its 
occasionally  preceding  the  jaundice,  and  of  its  often  occurring 
in  hepatic  disorders  independently  of  jaundice,  seem  to  show 
that  it  is  not  caused  hy  the  bile-pigment. 

6.  Cutaneous  Eruptions. — Urticaria,  lichen,  and  other  cuta- 
neous eruptions,  and  sometimes  boils  and  carbuncles,  are  occa- 
sionally observed  in  connection  with  jainidice.  Dr.  Graves' 
refers  to  eight  or  nine  cases  where  persons  suffering  from  acute 
rheumatism  became  suddenly  jaundiced  from  the  supervention 
of  '  hepatitis '  (congestion  of  liver?)  and  where  thejaimdice  was 
followed  by  urticaria.  I  have  not  myself  observed  this  sequence 
of  disease,  although  a  patient  now  under  my  care  (See  Lect. 
XI.)  has  been  suffering  from  congestion  of  the  liver  with 
jaundice,  which  Jippeared  shortly  after  recovery  from  an  attack 
of  acute  rheumatism  and  pericarditis.  Here,  however,  there 
has  been  no  urticaria. 

I  must  here  call  your  attention  to  a  very  remarkable  con- 
dition of  the  skin,  named  Vitiligoidea  or  Xanthcfasma,  vfhich  is 
now  and  then  observed  in  connection  with  jaundice,  and  to  which 
I  have  adverted  in  a  former  lecture  (p.  247).  The  condition  was 
first  described  by  the  late  Dr.  Addison  and  by  Sir  W.  Gull,  in 

'  Clinical  .Lect.  on  the  Practice  of  Medicine,  2nd  ed.  vol.  i.  p.  446. 


LECT.  IX.  PHENOMENA    AND    SYMPTOMS.  3I9 

a  joint  paper  in  the  Guy's  Hospital  Eeports,'  and  many  inter- 
esting examples  of  the  disease  have  of  late  years  been  exhibited 
to  the  Pathological  Society.^  The  disease  presents  itself  in  two 
forms,  either  independently  or  in  combination.  In  one  (Vitili- 
goidea  plana),  the  skin  of  the  eyelids,  of  the  palms  of  the  hands 
and  of  the  flexures  of  the  fingers,  and  the  membrane  of  the 
gums  present  opaque  white  patches,  with  the  surface  and  edges 
slightly  raised,  and  contrasting  strongly  with  the  surrounding 
jaundiced  (or  in  the  case  of  the  gums,  red)  surface.  These 
patches  are  not  at  all  indurated,  but  their  sensibility  is  in- 
creased ;  on  close  examination  the  cuticle  over  them  is  found  to 
be  healthy,  and  the  appearance  is  due  to  a  deposit  of  oil  in  the 
substance  of  the  cutis,  most  abundant  in  the  neighbourhood  of 
the  hair- follicles  (see  p.  251).  The  other  (Vitiligoidea  tuberosa) 
consists  of  scattered  tubercles  of  various  sizes,  some  as  largre  as 
a  pea,  together  with  shining  colourless  papules.  The  larger 
tubercles  are  tense  and  shining,  and  not  unlike  Molluscum  ;  but 
when  punctured  they  give  out  nothing  but  blood,  and  on  mi- 
croscopic examination  they  have  been  found  to  consist  of  tough 
fibrous  deposit  in  the  true  skin,  infiltrated  with  an  opalescent 
fluid  containing  fat  granules.  They  are  of  a  yellowish  colour, 
mottled  with  a  deepish  rose  tint,  and  with  small  capillary 
veins  here  and  there  ramifying  over  them,  and  they  are  accom- 
panied by  a  moderate  degree  of  irritation,  so  that  their  apices 
often  appear  rubbed  and  inflamed.  They  are  most  numerous 
on  the  face  and  ears,  on  the  outside  and  back  of  the  fore- 
arms, and  especially  about  the  elbows  and  knees,  where  they 
are  often  confluent.  I  have  already  pointed  out  to  you 
that  xanthelasma  may  occur  in  protracted  jaundice  from 
almost  any  cause,  and  that  it  is  also  observed  independencly 
of  jaundice.^ 

7.  Tlie  Temperature  of  the  body  in  jaundice  dependent  upon 
obstruction  of  the  bile-duct,  provided  there  be  no  concurrent 
cause  of  fever,  is  usually  slightly  below  the  normal  standard, 

'  Guy's  Hosp.  Eep.  2nd  Ser.  yol.  vii.  1851,  p.  265. 

^  A  case  is  also  reported  by  Dr.  Pavy  in  the  Proceedings  of  the  Eoy.  Med.  and 
Chir.  Soc,  June  12,  1866.  Se^  also  a  memoir  by  Mr.  Hutchinson,  Med.  Chir.  Trans. 
1871,  vol.  lir.  p.  171. 

^  It  is  -worth  mentioning  that,  in  two  cases  at  least,  a  similar  eruption  has  been 
observed  where  there  has  been  no  jaundice,  but  where  there  has  been  diabetes,  an 
observation  of  considerablp  interest  when  it  is  remembered  how  intimately  connected 
the  liver  is  with  the  pathology  of  diabetes.  (See  Addison  and  Gull,  in  Guy's  Hosp. 
Eep.  2nd  Ser.  vol.  ii.  p.  268  ;  and  Bristowe,  in  Path.  Trans,  vol.  xvii.  p.  414.) 


320  JAUNDICE.  LKCT.  ix. 

this  reduction  of  heat  being  due  to  the  impaired  activity  of  the 
chemical  processes  which  go  on  in  the  liver.     (See  Lect.  XIV.). 

8.  Sloumess  of  Pulse. — A  common  result  of  non-febrile  jaun- 
dice is  to  retard  the  action  of  the  heart  and  diminish  arterial 
tension.  Tlie  pulse  may  fall  to  50,  40,  or  even  20,  and  some- 
times it  is  also  irregular.  This  slowness  of  pulse  is  particularly 
]ioticeable  when  the  patient  is  recumbent ;  when  he  stands,  the 
circulation  is  quickened.  It  is  also  accelerated  when  there  is 
pj'rexia  in  addition  to  the  jaundice  ;  but  when  fever  precedes, 
the  pulse  usually  falls  on  the  supervention  of  the  jaundice. 
Hence  in  jaundice  the  frequency  of  the  pulse  is  a  less  reliable 
indication  of  fever  than  under  ordinary  circumstances,  and  we 
must  trust  mainly  to  the  temperature.  Slowness  of  the  pulse 
is  not  an  invariable  symptom  in  jaundice ;  it  is  most  common 
in  simple  or  catarrhal  jaundice,  although  not  restricted  to  this 
form.  It  has  not  yet  been  explained  why  it  is  present  in  some 
cases  and  absent  in  others.  The  natural  explanation  would  be 
that  it  is  due  to  one  particular  ingredient  of  the  bile,  which  does 
not  exist  in  the  blood  in  all  cases  of  jaundice.  Now  some 
experiments  of  Rohrig,^  continued  by  those  of  Dr.  Wickham 
Legg,-  and  Messrs.  Feltz  and  Ritter,^  of  Nancy,  upon  animals, 
have  shown  that  the  biliary  acid  salts  exercise  a  specific  para- 
lysing action  upon  the  ganglia  of  the  heart  and  retard  its  action, 
while  bile-pigment  has  no  such  effect.^  Slowness  of  pulse, 
therefore,  in  jaundice  may  indicate  the  presence  in  the  blood 
of  unchanged  biliary  acids,  although  to  this  view  it  has  been 
objected  that,  notwithstanding  their  diffusibility,  bile-acids 
cannot  be  discovered  in  the  urine  in  any  form  of  jaundice.  It 
may  be  added  that  I  have  repeatedly  known  the  pulse  sink  to 
36  or  40,  in  cases  of  hepatic  derangement  where  there  w^as  no 
jaundice. 

9.  Haemorrhages. — In  all  cases  where  jaundice  lasts  a  long 
time,  the  blood  becomes  impoverished  by  a  diminution  in  the 
proportion  of  red  corpuscles  and  fibrin,  and  as  a  result  of  this 
there  is  sometimes  developed  a  tendency  to  hsemorrhages  from 
the  various  mucous  membranes.  In  eases  of  protracted  jaun- 
dice from  mechanical  obstruction,  the  immediate  cause  of  death 
is  not  unfrequently  copious  haemorrhage  from  the  stomach  or 
bowels.  This  tendency  to  haemorrhage,  it  is  true,  is  particularly 
observed  in  conjunction  with  cerebral   symptoms    and   other 

'  An-hiv  fiir  Il.ilk.  Aug.  1863,  p.  385.  '  Laucet,  June  21,  1876. 

2  Proc.  Roy.  Soc.  1870,  No.  169. 


I 


LECT.  IX.  PHENOMENA    AND    SYMPTOMS.  32 1 

indications  of  blood-poisoning,  in  cases  of  jaundice  where  there 
is  no  obstruction  of  the  bile-duct ;  but  it  also  occurs  in  cases  of 
mechanical  jaundice  of  long-  standing,  when  the  secreting  tissue 
of  the  organ  has  in  a  great  measure  disappeared.  I  have  already 
(pp.  264  and  280)  called  your  attention  to  the  frequency  of 
hsemorrhages  in  cases  of  acute  atrophy  and  cirrhosis  of  the  liver, 
where  there  is  no  impediment  to  the  flow  of  bile  into  the  bowels, 

10.  General  Debility  and  Ancemia. — The  impaired  nutrition 
and  impoverished  blood  usually  induce  a  condition  of  general 
debility  and  exhaustion,  associated  with  hypochondriasis  and 
irritability  of  the  temper.  In  protracted  cases  there  is  a  great 
diminution  in  the  number  of  blood-corpuscles  and  correspond- 
ing anaemia. 

11.  Xannwjpsy,  or  Yellow  Vision. — In  some  cases  of  jaundice 
all  white  objects  appear  to  the  patient  yellow.     The  symptom 
is  extremely  rare  ;    Frerichs  and  other  experienced  observers 
have  never  met  with  it.     There  is  some  difference  of  opinion 
as  to  the  mode  of  production  of  this  yellow  vision.     If  the 
humors    of  the   eye  became   impregnated   with   bile-pigment, 
yellow  vision  might  be  expected  in  all  cases  of  jaundice  ;  but 
I  have  already  told  you  that  even  in  intense  jaundice,  the  rale 
is,  that  these  humors  and  the  crystalline  lens  are  not  in  the 
slightest   degree   tinged.     It   has   yet   to   be    shown   whether 
xanthopsy  is  peculiar  to  those  rare  cases  in  which  the  humors 
become  tinged  with  bile.    In  several  instances  where  xanthopsy 
was  present  Sir  Thomas  Watson  noted  a  distended  condition 
of  the  vessels  of  the  conjunctivae,  and  he  refers  to  a  case  of  Dr. 
Elliotson's,  where  yellow  vision  was  limited  to  one  eye  covered 
with  varicose  vessels ;  he  accordingly  concludes  that  it  is  onl}" 
when  the  vessels  of  the  eye  are  large  enough  to  transmit  blood- 
globules,  that  they  give  passage  to  the  bile-pigment  which  tinges 
the  humors  of  the  eye.^     Now  you  will  remember  that  there  is 
considerable  enlargement  of  the  conjunctival  vessels  in  the  case 

of  William  M (Case  CXXVII.),  who  for  a  short  time  had 

yellow  vision,  but  that,  although  he  no  longer  has  xanthopsy, 
the  enlargement  of  the  vessels  remains.  The  fact  that  the  yellow 
vision  often  intermits  Avithout  any  change  in  the  jaundice,  and 
that  it  is  frequently  absent  wlien  there  is  intense  jaundice  of 
the  cornea  and  of  the  other  tissues  of  the  eye  (Frerichs),  and 
the  statement  that  it  has  been  met  with  in  typhus  fever  where 
there  has  been  no  jaundice,  and  that  it  is  sometimes  associated 

1  Lect.  on  the  Principles  and  Practice  cf  Physic,  Sth  ed.  vol.  ii.  p.  677. 

T 


j-- 


JAUNDICE. 


with  other  derail  gem  ents  of  vision  such  as  night-blindness,  have 
led  many  to  regard  it  as  a  purely  nervous  symptom.  The  oph- 
thalmoscope may  possibly  clear  up  the  existing  doubts  respecting 
this  curious  symptom.  It  may  be  mentioned  that  after  the  use 
of  santonin  yellow  vision  is  sometimes  observed,  which  ceases 
as  soon  as  the  colouring  matter  is  eliminated  from  the  blood 
by  the  kidneys ;  it  would  be  interesting  to  know  if  the  santonin 
enters  the  humors  of  the  eye. 

12.  Cerebral  Symptoms,  such,  as  acute  delirium,  stupor,  coma, 
convulsions,  muscular  tremors,  subsultus,  carphology,  paralysis 
of  the  sphincters,  a  dry  brown  tongue,  and  other  indications  of 
the  '  typhoid  state  '  occasionally  supervene  in  cases  of  jaundice. 
They  are  most  common  in  cases  where  there  is  no  obstruction 
of  the  ducts,  but  they  may  also  occur  in  cases  of  long-standing 
obstruction,  where  all  or  a  greater  part  of  the  secreting  tissue 
has  been  destroyed.  Different  opinions  have  been  held  as  to 
their  cause.  In  exceptional  cases  they  are  due  to  inflammation 
of  the  membranes  covering  the  upper  surface  of  the  brain ;  but 
as  a  rule,  after  death  no  lesion  of  the  brain  or  of  its  membranes 
is  found  to  account  for  them,  and  they  must  therefore  be  due 
to  some  alteration  of  the  blood.  They  are  commonly  attributed 
to  poisoning  of  the  blood  with  bile,  and  many  experiments  have 
been  performed  on  animals  to  show  that  bile,  or  the  biliary 
acids,*  is  a  deadly  poison.  That  dogs  should  die  after  injection 
into  the  cellular  tissue  of  the  bile  of  other  dogs  is  not  extra- 
ordinary, and  admits  of  another  explanation  than  that  of  the 
essential  elements  of  bile  being  a  poison.  The  injection  of 
mucus  from  another  dog  would  probably  produce  a  like  result, 
and  all  bile  contains  mucus. 

Pure  bile,  from  which  the  mucus  has  been  removed,  has  been 
repeatedly  injected  into  the  large  veins  of  dogs  by  Frerichs  and 
other  observers,  without  any  cerebral  symptoms  or  bad  results 
ensuing,  except  that  death  in  some  instances  has  been  caused 
by  the  entrance  of  air  into  the  ^eins.'^  The  operation  has  been 
even  repeatedly  performed  on  tlie  same  animal  without  any 
lasting  injury.  But  it  is  scarcely  necessary  to  turn  to  experi- 
mental enquiries  on  the  lower  animals  for  evidence  on  the 
matter,  and  in  all  these  experiments  there  are  sources  of  fallacy. 
You  have  had  abundant  proof  in  the  wards,  that  the  blood  and 
tissues  of  the  human  subject  may  be  saturated  with  bile  for 

'  See,  f»r  exani^/le,  Harliy  on  Jjmnclice,  p.  39. 
'  Diseases  of  Liver,  Syd.  t-'oc.  Ed.  vol.  i.  p.  305. 


LKCT.  IX.  PHENOAfENA    AND    SYMPTOMS.  323 

months  (and  I  may  add,  for  years),  without  any  cerebral  sym- 
ptoms resulting.     Those  of  you  who  have  witnessed  the  case 

of  William  M (Case    CXXVII.),  who   for  many  months 

has  had  permanent  closure  of  the  bile-duct,  will  find  it  diffi- 
cult to  believe  that  bile  or  any  of  its  ingredients  is  a  deadly 
poison. 

An  American  physician.  Dr.  Austin  Flint,  jun.,  has  endea- 
voured to  show  that  the  cerebral  symptoms  in  jaundice  are  due 
to  the  retention  of  cholesterin  in  the  blood,  or  to  what  he  has 
designated  cliolestearcemia.  Cholesterin  is  a  crystalline  fatty 
matter,  and  is  one  of  the  constituents  of  the  complex  substance, 
bile.  Dr.  Flint  regards  it  as  an  excrementitious  product  of 
nervous  tissue,  the  elimination  of  which  from  the  body  is  one 
of  the  functions  of  the  liver.  ^  •  Arrived  in  the  bowel,  the  choles- 
terin, according  to  him,  is  converted  into  stercorin,  and  therefore 
it  is  not  found  in  the  fseces,  but  when  retained  in  the  blood  he 
believes  it  to  be  a  poison  like  urea.  But  if  the  non-excretion 
of  all  the  elements  of  bile  does  not  give  rise  to  cerebral  symptoms, 
it  is  difficult  to  understand  how  these  symptoms  can  result 
■from  the  retention  of  cholesterin  alone.  In  cases,  for  instance, 
of  permanent  closure  of  the  duct,  cholesterin  is  not  discharged 
from  the  liver  into  the  bowel,  nor  does  it  accumulate  in  the 
biliary  passages,  rior  does  it  produce  cerebral  symptoms  if  it  be 
retained  in  the  blood.  There  are  moreover  cases  on  record 
where  there  has  been  permanent  closure  of  the  bile-duct,  fol- 
lowed by  almost  entire  destruction  of  the  secreting  tissue  of  the 
liver,  and  where  in  consequence  this  organ  has  been  incapable  of 
eliminating  any  of  the  elements  of  the  bile  which  may  be  pre- 
formed in  the  bloocl,  and  yet  where  no  cerebral  symptoms  have 
been  noticed.  Arguing  from  such  cases  Dr.  Budd  contends  that 
when  cerebral  symptoms  occur  in  jaundice,  they  are  due  to  some 
peculiarly  noxious  matter  which  is  evolved,  in  consequence  of 
decomposition,  in  the  lobular  substance  of  the  liver.^  No  such 
noxious  matter,  however,  has  yet  been  discovered. 

The  cerebral  symptoms  in  jaundice  resemble  those  produced 
by  many  known  blood-poisons,  but  the  poison  is  more  probably 
generated  in  the  blood,  and  throughout  the  tissues  generally,  than 
in  the  liver  in  particular.  The  liver  is  not  merely  an  excretory 
organ,  but  unquestionably  exercises  an  important  influence  on 

'  American  JoLirn.  of  Med.  Science,  Oct.  1862;  and  Eecherclies  Exper.  siir  iine 
noiivelle  fonction  du  Foie,  Paris,  1868. 
-  Dis.  of  Liver,  3rd  edit.  pp.  270,  475. 

Y  2  .  " 


324  JAUNDICE.  i-FXT.  IX. 

the  metamorphoses  of  matter  constantly  taking  place  in  the 
blood  and  tissues,  and  although  the  precise  nature  of  these 
changes  is  insufficiently  known,  there  are  reasons  for  believing 
that  the  liver  is  instrumental  in  the  production  of  urea  and 
uric  acid.  When,  for  example,  the  functions  of  the  liver  are 
arrested,  one  result  is  that  urea  is  not  elaborated,  but  sub- 
stances such  as  leucin  and  tyrosin,  and  perhaps  others  with 
wliicb  we  are  as  yet  imperfectly  acquainted,  of  a  composition 
intermediate  between  urea  and  the  protein  compound  (see 
p.  263),  are  developed  ;  while  the  materials  which  ought  to  be 
eliminated  from  the  body  as  urea  and  uric  acid  accumulate 
in  the  blood.  In  acute  yellow  atroi)h3'  and  in  the  yellow  fever 
of  the  tropics  the  occurrence  of  cerebral  symptoms  is  marked 
by  an  extraordinary  diminution  of  urea  in  the  urine.  The 
pathology  in  fact  of  the  cerebral  symptoms  in  jaundice  is 
probably  very  similar  to  what  I  have  endeavoured  to  prove  to 
you  is  the  pathology  of  the  typhoid  state  in  all  diseases.'  But 
to  this  subject  we  shall  return  after  considering  the  theory  of 
jaundice. 

THEORY    OF    JAUNDICE. 

All  cases  of  jaundice  may  be  referred  to  one  of  two  classes, 
viz. — 

I.  Cases  in  which  there  is  a  mechanical  impediment  to  the 
flow  of  bile  into  the  duodenum,  and  where  the  bile  is  in  con- 
sequence retained  in  the  biliary  passages,  and  thence  absorbed 
into  the  blood. 

II.  Cases  in  which  there  is  no  impediment  to  the  escape  of 
bile  from  the  liver. 

These  two  forms  of  jaundice  have  long  been  recognised  ;  but 
great  differences  of  opinion  have  been  held,  and  still  exist,  as  to 
the  mode  of  production  of  the  jaundice  in  the  second  class  of 
cases,  and  yet  these  are  the  cases  which  are,  j^erhaps,  the  most 
coinmon  in  practice. 

When  any  obstruction  exists  to  the  flow  of  the  bile  through 
the  hepatic  or  the  common  duct,  the  way  in  which  jaundice 
arises  is  sufficiently  clear.  The  bile-ducts  and  the  gall-bladder 
become  distended  with  bile,  which  is  absorbed  into  the  blood 
by  the  lymphatics  and  the  veins.     This  was  satisfactorily  proved 

'  Hoc  Altstrict,  of  a  Clinical  Leoturo  on  tlio  Patholopy  aiiil  Treatment  oi  the 
Tvphoid  State  in  diffsrent  JJi.-casca.     Erit.  ilcd.  Joiini.  Jan.  4,  1868. 


LECT.  IX.  THEORY    OF    JAUNDICE.  325 

at  the  beginning  of  this  century  by  the  experiments  of  Dr. 
Saunders,^  which  have  since  been  confirmed  by  other  observers. 
If  a  ligature  be  applied  to  the  hepatic  duct  of  a  dog,  and  the 
animal  be  killed  after  two  hours,  the  lymphatics  in  the  walls  of 
the  bile-ducts,  which  are  very  numerous,  are  seen  to  be  distended 
with  a  yellow  fluid ;  the  fluid  in  the  thoracic  duct  is  also  yellow, 
and  so  likewise  are  the  intervening  lymphatic  glands.  In 
patients  also  who  die  of  obstruction  of  the  bile-duct,  the 
lymphatics  of  the  liver  are  often  found  to  contain  bile.  On  the 
other  hand,  the  serum  of  blood  taken  from  the  hepatic  vein  two 
hours  after  ligature  of  the  common  duct  is  found  to  contain 
much  more  bile-pigment  than  that  of  blood  taken  from  the 
jugular  vein.2  This  preponderance  of  bile-pigment  in  the  blood 
of  the  hepatic  veins  over  that  of  the  general  circulation  shov/s 
that  bile,  in  cases  of  obstruction  of  the  gall-duct,  is  also  directly 
absorbed  by  the  veins.  Indeed,  as  we  shall  presently  find, 
there  is  reason  to  believe  that  even  when  there  is  no  obstruc- 
tion, bile  is  constantly  passing  from  the  gall-bladder  and 
biliary  passages  into  the  circulation,  in  virtue  of  the  law  of 
diffusion  of  fluids  through  animal  membranes.  Under  ordinary 
circumstances  jaundice  does  not  result,  because  the  bile  is  at 
once  transformed  in  the  blood,  and  in  its  turn  influences  the 
metamorj^hosis  of  other  matters,  the  products  of  which  meta- 
morphosis are  eliminated  by  the  urine.  But  in  the  distension 
of  the  biliary  .passages  consequent  on  obstruction,  the  pressure 
upon,  and  the  extent  of,  the  diffusing  surface  are  increased, 
and  consequently  more  bile  enters  the  blood  than  can  undergo 
the  metamorphosis  necessary  for  its  elimination  by  the  urine. 
Even  in  obstruction,  however,  the  intensity  of  the  jaundice  (or 
the  amount  of  unchanged  bile  accumulated  in  the  blood)  will 
vary  with  the  amount  of  bile  secreted  by  the  liver,  the  rapidity 
with  which  it  is  eliminated  by  the  kidneys,  and  the  activity  of 
oxydation  going  on  in  the  blood. 

But  in  a  large  proportion  of  cases  there  is  no  mechanical 
impediment  to  the  escape  of  bile  from  the  liver,  and  then  an 
explanation  of  the  jaundice  is  less  obvious.  Boerhaave  and 
Morgagni  long  ago  suggested  that  the  jaundice  in  these  cases 
was  the  result  of  a  suspended  secretion.     Thej'  maintained  that 

'  Treatise  on  the  Structure,  Economy,  and  Diseases  of  the  Liver,  aul  on  Eile  and 
Biliary  Concretion,  3rd  ed.  1803. 

"^  Dr.  Legg  states  tliat  he  has  recently  repeated  this  experiment  in  the  dog  without 
success.     St.  Bartholomew's  Hospital  Eeports,  toI.  ix.  1873. 


326  JAUNDICE.  lECT.  IX. 

the  function  of  the  liver  was  merely  to  separate  the  elements  of 
bile  which  were  alread}-  formed  in  the  blood,  and  that  when 
anything  interfered  with  this  function  of  the  liver,  the  blood 
retained  the  ingredients  of  the  bile,  and  the  result  was  jaundice. 
Altliough  this  view  was  strenuously  opposed  in  this  country  at 
the  beginning  of  the  century  by  Dr.  Saunders,  who  contended 
that  '  in  every  case  of  jaundice  bile  must  be  secreted  and 
carried  into  the  blood-vessels,' '  it  is  the  view  which  is  generally 
received  at  the  jDresent  day.  Dr.  Budd,  for  instance,  in  his 
treatise  on  Diseases  of  the  Liver  remarks,  '  in  these  cases  the 
most  obvious  explanation  of  the  facts  is,  that  the  biliary  pig- 
ment exists  in  the  blood,  and  that  in  consequence  of  defective 
action  of  the  secreting  cells,  it  is  not  eliminated  as  it  should  be 
in  the  liver.'  ^  It  is  right  to  add,  however,  that  Dr.  Budd  makes 
a  special  exception  with  regard  to  the  biliary  acids. ^  '  The  most 
skilful  chemists,'  he  says,  '  who  have  recently  analysed  the 
portal  blood,  have  failed  to  detect  the  biliary  acids  in  it,  and 
have  come  to  the  conclusion  that  these,  at  least,  are  formed  in 
the  liver.' ^  This  view,  that  the  liver  manufactures  the  bile-acids, 
Avhiie  it  merely  excretes  the  bile-pigment,  is  also  adopted  by 
Dr.  G.  Harley  in  his  essay  on  Jaundice.^ 

It  seems  to  me,  however,  that  there  are  weighty  objections 
to  the  view,  that  even  the  bile-pigment  is  formed  in  the  blood 

'  Op.  cit.  p.  107.  ^  Op.  cit.  p.  468. 

'  Bile  is  a  very  complex  substance.     Its  composition,  according  to  Gonip-]-5ps;inez, 
is  as  follows : — 

AVater 8227  to  908-1 

Solid  matter 177-3  „     91-3 

Bile-acid  salts 107-9  „     56-5 

Fat  and  cholesterin 47-3  „     30-9 

Mucus  and  pigment 23-9  „     14-5 

Ash 10-8  „       6-3 

Tm'o  acids  have  been  found  in  the  bile,  Avhich  have  been  named  by  Lehmann 
glycocholie  and  taurocholic  acid.  According  to  this  chemftit  tliese  acids  are  formed 
by  the  conjugation  of  cholic  acid  with  glycin  (gelatin-sugar)  and  taurin  respec- 
tively, and  thcj'  are  united  in  the  bile  with  soda  as  a  base.  The  composition  of 
glycocholie  acid  is  C._,,,II|3N0„,  and  that  of  taurocholic  acid,  C.^ijIIjsNOjS.  Two  modi- 
fications of  bile-pigment  have  been  found,  viz.  a  brown  pigment,  named  cholepyrrhin, 
bilifulvin,  or  bilirubin,  and  a  green  pigment,  biliverdin  ;  cholepyrrhin  is  conver- 
tiljle  into  biliverdin.  Very  little  is  known  of  the  chemical  nature  of  these  sub- 
stances ;  there  are  probably  other  modifications  of  the  pigmentary  matter,  which,  as 
well  as  those  mentioned,  are  the  products  of  the  transformation  or  oxydation  of  one 
jirimitivo  substance.     See  also  Lecture  XIV. 

*  Op.  cit.  pp.  40,  467. 

?  Jaundice,  iis  Pathology  and  Treatment,  by  G.  Ilarley,  M.D.  Lond.  1803. 


i,ECT.  IX.  THEORY    OF    JAUNDICE.  32/ 

and  merely  excreted  by  the  liver,  some  of  vvliicli  may  be  men- 
tioned. 

1.  Although  bile-pigment  appears  to  be  derived  from  the 
colouring  matters  of  the  blood  and  may  be  produced  from  this 
by  the  action  of  chemical  reagents,  or  may  even  be  developed 
in  extravasations  as  a  pathological  product,^  it  has  not  yet  been 
satisfactorily  shown  that  bile-pigment,  as  such,  exists  ready 
formed  in  the  blood  of  persons  v^^ho  have  not  jaundice. 
Frerichs  denies  that  it  ever  has.  Lehmann,  who  has  investi- 
gated with  great  care  the  changes  which  the  blood  undergoes 
in  passing  through  the  liver,  has  never  been  able  to  detect  the 
colouring  matter  of  bile  in  portal  blood,  and  infers  that  this  as 
well  as  the  bile-acids  must  be  formed  in  the  liver  itself.^  The 
blood  of  the  hepatic  artery  has  been  examined  with  a  like  result. 
It  is  obvious  that  if  bile-pigment  exist  in  healthy  blood  at  all, 
its  quantity  must  be  very  minute ;  and  when  it  is  remembered 
that  the  daily  quantity  of  bile  manufactured  in  the  liver  is 
about  two  pints,  and  yet  that  jaundice  is  not  a  normal  condition, 
it  seems  impossible  that  all  the  bile-pigment  secreted  by  the 
liver  can  be  formed  in  the  blood ;  and  it  is  not  probable  that 
part  is  formed  in  the  blood,  and  part  by  the  liver. 

2.  The  discovery  by  a  few  observers  of  a  small  quantity  of 
bile-pigment  in  what  appeared  normal  blood  does  not  prove 
that  it  was  formed  in  the  blood,  for  it  is  conceivable  that  it 
may  have  been  formed  in  the  liver  and  been  then  absorbed.  It 
is  probable,  indeed,  as  I  shall  endeavour  to  prove  to  you  pre- 
sently, that  bile-pigment  is  constantly  being  absorbed  into  the 
blood,  becoming  altered  in  the  act  of  absorption  or  immediately 
after ;  and  if  this  be  so,  it  is  quite  possible  that  a  trace  of  it 
should  occasionally  remain  unaltered  in  the  blood  without 
giving  rise  to  obvious  jaundice. 

3.  If  the  constituents  of  bile  are  formed  in  the  blood,  intense 
jaundice  ought  at  once  to  follow  the  extirpation  of  the  liver  in 
any  of  the  lower  animals,  in  like  manner  as  urea  accumulates 
in  the  blood  after  removal  of  the  kidneys.  But  so  far  from  this 
being  the  case,  Mliller,  Kunde,  Lehmann,  and  Moleschott  have 

'  See  Virchow"s  Cellular  Pathology,  Engl.  Transl.  pp.  128,  145,  and  Kuhne, 
Lehrbuch  der  physiologischen  Chemie,  Leipzig,  1866,  p.  89.  Analyses  of  the  bile- 
pigments,  which  have  been  communicated  to  the  Koyal  Society  by  Dr.  Thudichuui, 
tend  to  show  that  they  have  no  relation  to  hsematin,  as  was  formerly  supposed. 
(Proc.  Eoy.  Soc.  1867,  vol.  xvi.  p.  220.) 

■■^  Physiological  Chemistry,  Dr.  Day's  transl.  vol.  ii.  p.  87. 


328  JAUNDICE.  LBCT.  IX. 

repeatedly  extirpated  the  liver  of  frogs,  and  have  invariably 
failed  to  find  a  trace  either  of  the  biliary  acids,  or  of  the  colour- 
ing matter  of  the  bile,  in  the  blood,  the  urine,  or  the  muscular 
tissue.' 

4.  It  often  happens  that  from  various  diseases,  such  as  fatty 
and  waxy  degeneration,  cancer,  and  cirrhosis,  the  secreting 
tissue  of  the  liver  in  the  human  subject  is  for  the  most  part  or 
entirely  destroyed,  bile  is  no  longer  secreted,  and  yet  no  jaun- 
dice results.  Several  cases  of  this  sort  are  referred  to  by  Haspel, 
where  the  gall-bladder  after  death  contained  only  a  little  white 
mucus. ^  Frerichs  also  records  a  case  of  fatty  liver  where  the 
contents  of  the  bowels  were  pale,  the  gall-bladder  empty,  and 
the  biliary  ducts  coated  with  a  greyish  mucus,  notwithstand- 
ing which  the  skin  was  of  a  chalky  paleness,  and  the  urine 
contained  no  bile-pigment.^  Similar  observations  have  been 
made  by  Dr.  Budd,  in  cases  of  waxy  disease  and  cancer  of  the 
liver,**  and  several  instances  of  a  like  nature  have  come  under 
my  own  notice.  If  bile  be  formed  in  the  circulating  blood,  it 
is  difficult  to  account  for  what  becomes  of  it  in  these  cases. 

These  considerations  make  it  very  doubtful  if  any  form  of 
jaundice  can  with  propriety  be  attributed  to  a  suppression  of  the 
hepatic  functions.  It  remains  then  to  be  considered  if  any  more 
satisfactory  explanation  can  be  offered  of  those  cases  of  jaun- 
dice in  which  there  is  no  impediment  to  the  flow  of  bile  from 
the  liver  into  the  duodenum. 

A  solution  of  the  difficulty  has  been  proposed  by  Professor 
Frerichs  of  Berlin.  According  to  this  distinguished  observer, 
a  large  proportion  of  the  colourless  biliary  acids  formed  in  the 
liver  is  either  directly  taken  upb}'  the  blood  in  the  hepatic  vein, 
or  is  absorbed  from  the  bowel.  Under  ordinary  circumstances, 
these  biliary  aCids  become  oxydised  and  assist  in  forming  the 
large  quantity  of  taurin  found  in  healthy  lung  and  the  pigments 
voided  in  the  urine  ;  but  these  normal  metamorphoses  are  liable 
to  interru2-)tion  by  nervous  agencies,  or  by  poisons  in  the  blood, 
and  then  the  bile-acids,  not  being  sufficiently  oxydised,  are  con- 
verted into  bile-pigment  in  the  blood,  and  the  result  is  jaundice.* 
This  view  has  been  supported  by  two  experiments  intended  to 
show:  1.  That  bile-pigment  can  be  obtained  artificially  from 
the  bile-acids,  by  the  action   of  concentrated  sulphuric  acid  ; 

*  Carpenter's  Human  Physiology,  7tli  ed.  p.  434. 

*  Malad.  d'Algc'rie,  i.  262.  »  Op.  cil.  Kng.  Ed.  i.  83. 

*  Op.  cit.  pp.  329,  411.  »  Op.  cir.  vol.  i.  pp.  89,  394. 


i.KCT.  IX.  THEORY    OF    JAUNDICE.  329 

and,  2.  That,  colourless  biliary  acids,  when  injected  into  the 
veins  of  dogs,  are  converted  in  the  blood  of  these  animals  into 
bile-pigment.  These  experimental  results,  as  well  as  the  con- 
clusions drawn  from  them,  are  still  the  subject  of  much  discus- 
sion. They  have  been  controverted  by  Kyhne,^  Hoppe,  Harley,^ 
&c.,  but  supported  by  Staedeler,^  Neukomm,^  Folwarczny,^ 
Rohrig-,''  &c.  It  has  been  contended  on  the  one  hand,  that  the 
biliary  acids  in  these  experiments  are  decomposed  in  the  blood ; 
and  on  the  other,  that  in  whatever  manner  they  find  their  way 
into  the  blood,  they  are  excreted  unchanged  by  the  kidneys. 
The  majority  of  observers  seem  to  concur  with  Frerichs  ;  and  his 
view  is  confirmed  by  the  circumstance,  that  of  the  large  quan- 
tity of  bile-acids  secreted  by  the  human  liver  and  subsequently- 
absorbed  none  appears  in  the  urine.  But  the  decision  of  the 
question  at  issue  is  not  of  material  importance  for  explaining 
those  cases  of  jaundice  in  which  there  is  no  impediment  to  the 
escape  of  bile  from  the  liver,  inasmuch  as  there  are  grounds  for 
believing  that  not  only  in  jaundice  but  in  health,  a  portion  of  the 
bile-pigment,  as  well  as  of  the  bile-acids  formed  in  the  liver,  is 
absorbed  into  the  blood.^ 

1.  The  quantity  of  bile-pigment  discharged  with  the  fffices 
is  but  a  fraction  of  what  is  calculated  to  be  secreted  by  the 
liver. ^  Speaking  of  the  principal  constituents  of  bile,  Dr.  Car- 
penter ^  remarks  :  '  the  further  we  descend  in  the  intestinal 
canal,  the  less  of  them  do  we  meet  with  : '  and  again  he  ssijs  : 
'  of  the  bile  which  is  poured  into  the  alimentary  canal,  a  large 
part  is  certainly  reabsorbed,  its  constituents  being  destined  to 
undergo  oxydation  and  be  eliminated,  for  the  most  part  by  the 
respiratory  processes :  and  it  is  probably  from  this  reabsorbed 
portion  of  the  bile  that  the  sulphur  of  the  urine  is  derived.'" 
According  to  Dr.  Bence  Jones,  also,  '  the  colouring  matter  (of  the 

'  Virchow's  Archives,  vol.  xiv.  pts.  3  and  4,  Sept.  1858,  and  Beale's  Archives  of 
Medicine,  vol.  i.  p.  342. 

^  Pathology  and  Treatment  of  Jaundice,  1863. 

'  See  my  Preface  to  the  English  Edition  of  Frerichs  on  the  Liver,  pp.  xv,  xvi. 

*  Archiv  fiir  Heilkunde,  Aug.  1863,  p.  385. 

'  It  may  be  thought  improbable  that  the  liver  should  secrete  from  the  portal 
vein  a  material  which  is  afterwards  to  be  absorbed  by  the  branches  of  the  same 
vessel.  But  it  has,  perhaps,  been  too  readily  assnmed  from  the  comparatively  large 
siz9  of  the  vena  portse  that  it  furnishes  all  the  materials  of  bile  (see  Lecture  XIV.) 

"  For  further  evidence  on  this  subject  the  reader  is  referred  to  the  author's 
Croonian  Lectures  on  Functional  Derangements  of  the  Liver.  (Lecture  XIV.  in  tliis 
Volume.) 

^  Carpenter's  Princ.  of  Hum.  Physiology,  5th  ed.  pp.  102,  353,  374. 


330  JAUNDICE.  LKCT.  IX. 

bile)  underg'oes  clianges  in  the  intestines,  and  some  of  it  most 
probably  in  health  is  carried  into  the  blood  and  textures,  and  is 
finally  removed  in  the  colouring  matter  of  the  urine.'  •  It  is  the 
knowledge  of  this  circumstance  that  offers  the  only  satisfactory 
explanation  of  the  remarkable  discrepancy  of  opinion  in  the 
jn'ofession  respecting  mercury  and  other  substances,  which  are 
supposed  to  exercise  some  specific  effect  upon  the  liver  in  sti- 
mulating it  to  an  increased  secretion  of  bile.  The  practical 
physician  gives  a  dose  of  calomel,  finds  the  quantity  of  bile  in 
the  motions  greatl}'  increased,  and  argues  that  the  liver  has 
been  stimulated  to  an  increased  secretion ;  but  the  physiologist 
ties  the  common  bile-duct,  makes  a  fistulous  opening  into  the 
gall-bladder,  and  then  finds  that  calomel  has  no  effect  on,  or 
even  diminishes,  the  amount  of  bile  that  drains  away  through 
the  fistula.^  Mercury  and  allied  purgatives  probably  produce 
bilious  stools  hy  irritating  the  upper  part  of  the  bowel,  and 
sweeping  on  the  bile  before  there  is  time  for  its  absorption ; 
irritating  articles  of  diet  will  often  produce  precisely  the  same 
effect.  Calomel  is  of  unquestioned  utility  in  congestion  of  liver, 
but  if  it  acted,  as  is  usually  argued,  by  stimulating  the  liver  to 
increased  secretion,  it  might  be  expected  to  increase  the  con- 
gestion rather  than  diminish  it.  It  is  possible,  however,  that 
the  irritation  of  the  duodenum  by  purgatives  may  be  reflected 
to  the  gall-bladder,  and  cause  it  to  contract,  and  that  the  eva- 
cuation of  this  viscus  may  account  in  part  for  the  increased 
quantity  of  bile  in  the  stools. 

2.  From  Avhat  is  now  known  of  the  diffusibility  of  fluids 
through  animal  membranes,  it  is  impossible  to  conceive  bile  long 
in  contact  with  the  lining  membrane  of  the  gall-bladder,  bile- 
ducts,  andintestine,  without  aportion  of  it  (including  the  dissolved 
pigment)  passing  into  the  blood.  A  circulation  in  fact  is  con- 
stantly taking  place  between  the  fluid  contents  of  the  bowel  and 
the  blood,  the  existence  of  which  till  within  the  last  few  years 
was  quite  unknown,  and  which  even  now  is  too  little  heeded.^ 
'  It  is  now  known,'  says  Dr.  Parkes,  in  his  Gulstonian  Lectures 
on  Pyrexia,  'that  in  varying  degrees,  there  is  a  constant  transit 

'  St.  Georgf's  Hospital  Reports,  vol.  i.  p.  192. 

*  On  the  Influence  of  Mercuriiil  Preparations  on  the  Secretion  of  Bile,  by  George 
Scott,  M.IJ.     E-ale'.s  Archives  of  Medicine,  vol.  i.  209. 

'  For  instance,  the  purging  of  cholera  is  probably  the  result  of  some  stoppage  in 
this  intestinal  circulation — of  a  diminisheil  power  of  absorption,  rather  than  of  an 
increased  exlialation  from  the  mucous  membrane  of  the  bowel.  Numerous  fact.s  render 
it  probalde  that  in  cliolera  tliu  power  of  absorption  is  greatly  impaired  or  abolisheiL 


LKCT.  IX.  THEORY    OF    JAUNDICE.  331 

of  fluid  from  the  blood  into  tlie  alimentary  canal,  and  as  rapid 
reabsorption.  The  amount  thus  poured  out  and  absorbed  in 
twenty-four  hours  is  almost  incredible,  and  of  itself  constitutes 
a  secondary  or  intermediate  circulation  never  dreamt  of  by 
Harvey.  The  amount  of  gastric  juice  alone,  passing  into  the 
stomach  in  a  day  and  then  reabsorbed,  amounted  in  the  case 
lately  examined  by  Grlinewaldt,'  to  nearly  23  imperial  pints. 
If  we  put  it  at  12  pints  we  shall  certainly  be  within  the  mark. 
The  pancreas,  according  to  Kroeger,  furnishes  12^  pints  in 
twenty-four  hours,  while  the  salivary  glands  pour  out  at  least 
3  pints  in  the  same  time.  The  amount  of  the  bile  is  probably 
over  2  pints.  The  amount  given  out  by  the  intestinal  mucous 
membrane  cannot  be  guessed  at,  but  must  be  enormous.  Alto- 
gether the  amount  of  fluid  effused  into  the  alimentary  canal  in 
twenty-four  hours  amounts  to  much  more  than  the  whole 
amount  of  blood  in  the  body  ;  in  other  words,  every  portion  of 
the  blood  may,  and  possibly  does,  pass  several  times  into  the 
alimentary  canal  in  twenty-four  hours.  The  effect  of  this  con- 
tinual outpouring  is  supposed  to  be  to  aid  metamorphosis ;  the 
same  substance,  more  or  less  changed,  seems  to  be  thrown  out 
and  reabsorbed  until  it  be  adapted  for  the  repair  of  tissue  or 
become  effete.'  ^ 

It  is  in  the  course  of  this  osmotic  circulation  that  the  con- 
stituents of  bile  are  taken  up  into  the  blood,  becoming  trans- 
formed in  the  process  of  absorption  into  products  which  are 
eliminated  by  the  lungs  and  kidneys,^  while  at  the  same  time 
they  assist  in  the  assimilation  of  the  nutritive  materials  derived 
from  the  food.  And  here  we  have  an  explanation  of  those  cases 
of  jaundice  where  there  is  no  impediment  to  the  flow  of  bile 
from  the  liver.  Under  normal  conditions,  the  whole  of  the  bile 
that  is  absorbed  is  at  once  transformed,  so  that  neither  bile- 
acids  nor  bile-pigment  can  be  discovered  in  the  blood  or  in  the 
urine,  and  there  is  no  jaundice.  But  in  certain  morbid  states 
the  absorbed  bile  does  not  undergo  the  normal  metamorphoses ; 
it  circulates  in  the  blood  and  stains  the  skin  and  other  tissues. 
The  morbid  states,  which,  so  far  as  we  know,  conduce  mainly 

'  An  account  of  t  his  case,  abstracted  by  me  from  Griinewaldt's  Latin  Memoir, 
will  be  found  in  Beale's  Archives  of  Medicine,  a'oI.  i.  p.  270.     C.  M. 

2  Med.  Times  and  Gazette,  April  7,  1855,  p.  333. 

^  In  various  diseased  conditions  of  the  liver,  even  when  there  is  no  jaundice,  or 
bile-pigment  in  the  urine,  this  fluid  is  rendered  very  dark,  sometimes  almost  black, 
by  boiling  and  adding  nitric  acid. 


332  JAUNDICE.  t.KCT.  IX. 

to  this  result,  are  precisely  those  in  which  we  might  expect 
abnormal  blood-metamorphosis,  viz. — 

1.  Certain  poisons,  such  as  those  of  yellow  fever,  relajDsing 
fever,  pyaemia,  and  more  rarely  those  of  remittent  fever,  typhus, 
scarlatina;  also  snake-poison,  chloroform,  &c. 

2.  Nervous  influences,  such  as  a  sudden  fright,  violent  rage, 
great  or  protracted  anxiety,  and  concussion  of  the  brain. 

8.  A  deficient  supply  of  oxygen,  as  happens  in  certain 
cases  of  pneumonia  in  persons  living  in  confined  and  crowded 
dwellings. 

4.  An  excessive  secretion  of  bile,  esjiecially  when  conjoined 
with  constipation.  In  this  case,  unless  the  bile  be  removed  by 
purging,  the  quantity  absorbed  may  be  too  great  to  undergo  the 
normal  metamorphosis,  and  the  presence  in  the  blood  of  the 
untransformed  bile  causes  jaundice. 

According  to  this  view,  the  only  pathological  difference 
between  jaundice  from  obstruction  and  jaundice  independent  of 
obstruction  of  the  common  bile-duct  is  that  in  the  former  case 
none  of  the  bile  secreted  by  the  liver  can  escape  from  the  body 
by  the  faeces,  and  consequently  all  that  is  secreted,  after  the 
gall-bladder  and  biliary  passages  are  fully  distended,  is  absorbed 
into  the  blood,  the  quantity  thus  absorbed  being  far  too  great  to 
undergo  the  normal  metamorphoses ;  while  in  the  latter  case 
bile  passes  into,  and  is  discharged  from,  the  bowel,  as  usual, 
but  that  which  is  absorbed,  which  in  quantity  may  not  exceed 
that  which  is  absorbed  in  health,  remains  unchanged  in  the 
blood.'     As  might  have  been  expected,  the  jaundice  in  the  former 

'  AcL'ordiiig  to  Dr.  Moxon  and  Dr.  Hilton  Fa.ffgc,  'tliis  theory,  that  jaumlice  is  in 
ill!  ca.ses  due  to  reabsorption,  is  entirely  inconsistent  with  the  fact  that  in  jaundice  the 
Liliary  passages  are  almost  ahvays  found  to  contain,  not  Ijile.but  an  almost  colourKsa 
mucus.  This  is  the  case,  not  only  in  acute  yellow  atrophy  of  the  liver,  but  also  when 
the  ducts  are  permanently  obstructed  by  cancerous  growths,  gall-stones,  &c.'  (Trans. 
I'jith.  Soc.  1873,  vol.  xxiv.  p.  129;  and  Guy's  IIosp.  Eep.  187o,  vol.  xx.)  This 
argument  has  been  met  by  Dr.  Wickham  Legg,  Avho  writes  as  follows :  '  The  presence 
of  a  colourless  fluid  in  the  gall-l)ladJer  and  the  bile-ducts  was  formerly  looked  upon 
as  evidence  that  the  liver  had  ceased  to  secrete  bile.  Indeed,  a  rcent  writer  (W. 
Jloxon)  is  still  plainly  of  this  opinion.  But,  to  my  mind,  the  evidence  seems  rather 
the  contrary.  It  should  be  remembered  that  it  was  the  large  ducts  which  were  seen 
to  be  filled  with  this  colourle.><s  fluid,  and  that  nothing  is  said  of  the  state  of  the 
smaller  duct.s,  of  the  interlobular  and  capillary  ducts.  These  continue  to  receive  the 
bile  poured  into  them  by  the  liver-cells,  but  the  bile  does  not  reach  the  large  ducts 
because  the  small  ducts  are  shut  oflT  from  the  large,  either  by  plugs  of  this  tenacious 
fluid  or  by  gravel.  In  a  case  which  I  recently  examined  at  fet.  Bartholomew's,  the 
large  ducts  were  perfectly  colourless  ;  but,  by  gently  pressing  the  liver,  a  yellow  fluid 
could  be  made  to  issue  from  the  small  ducts.  Also,  by  careful  dissection,  the  small 
ducts  could  bo  seen  to  be  stained  j'ellow.'     (Brit.  Med.  Journ.  1874.) 


LECT.  IX.  THEORY    OF    JAUNDICE.  333 

case  is  much,  more  intense  than  in  the  latter,  although  where  an 
obstruction  of  the  bile-duct  has  lasted  long-  the  jaundice  often 
becomes  paler,  not  from  removal  or  diminution  of  the  obstruc- 
tion, but  from  the  secreting  tissue  of  the  liver  being  destroyed 
and  comparatively  little  bile  being  secreted;  while  in  cases 
Avhere  there  is  no  obstruction  of  the  bile-duct,  the  intensity  of 
the  jaundice  will  vary  according  to  the  amount  of  bile  which  is 
absorbed  and  the  degree  of  derangement  of  th.e  blood-metamor- 
phoses. 

Lastly,  we  may  enquire  what  explanation  the  theory  of 
jaundice  now  advanced  gives  of  the  cerebral  symptoms  met  with 
in  certain  cases  and  already  referred  to  (p.  322).  From  what 
has  been  stated  it  is  very  probable  that  the  entrance  of  bile  into 
the  blood  is  necessary  to  perfect  those  metamorphoses  from  which 
materials  for  the  urinary  solids  are  derived.  At  all  events, 
this  seems  certain,  that  when  the  secreting  tissue  of  the  liver  is 
destroyed,  as  in  acute  atrophy  and  in  certain  cases  of  long- 
standing obstruction  of  the  bile-duct,  these  metamorphoses  are 
imperfectly  executed.  Urea  is  not  formed  in  sufficient  quantity, 
and  substances  such  as  leucin  and  tyrosin,  of  intermediate  com- 
position between  it  and  the  protein  compounds  (see  p.  263), 
accumulate  in  the  blood  and  tissues  and  appear  in  the  urine. 
These  are  the  circumstances  under  which,  cerebral  symptoms 
occur  in  cases  of  so-called  '  suppression  of  bile.'  The  mere  pre- 
sence of  bile  in  the  blood,  as  I  have  already  shown  you  (p.  322), 
will  not  account  for  them,  and  indeed  in  those  cases  where 
cerebral  symptoms  are  most  apt  to  supervene,  the  jaundice  as 
a  rule  is  less  intense  than  it  often  is  when  they  are  absent. 

The  detailed  consideration  of  the  various  causes  of  jaundice, 
^.nd  of  the  means  of  distinguishing  them,  we  must  reserve  for 
subsequent  lectures. 


334  JAUNDICE. 


LECTUEE   X. 
JAUNDICE. 

CLASSIFICATION    OF    CAUSES    OF    JAUNDICE — JAUNDICE    FROM    OBSTRUCTION    OF 
THE    BILE-DUCT. 

Gentlemen, — After  the  preliminary  remarks  on  tlie  subject  of 
jaundice  made  in  the  preceding  lecture,  we  may  now  proceed 
to  consider  its  different  causes,  and  the  means  of  distinguish- 
ing thera. 

All  cases  of  jaundice,  as  I  have  told  you,   may  be  con- 
veniently grouped  under  the  two  heads  of — 

A.  Jaundice   resulting   from    obstruction  of  the  Common 
Bile-Duct ;  and, 

B.  Jaundice  independent  of  any  obstruction  of  the   Bile- 
Duct. 

The  numerous  causes  comprised  under  each  of  these  heads 
may  be  seen  from  this  Table : 


TABULAR  VIEW  OF  THE  CAUSES  OF  JAUNDICE. 


A.    JAUNDICE  FROM  MECHANICAL  OBSTRUCTION  OF  THE 
BILE-DUCT. 

I.  Obstruction  by  Foreign  Bodies  within  the  duct. 

1.  Gall-stones  and  inspissated  bile. 

2.  Hydatids  and  Distomata. 

3.  Foreign  bodies  from  the  intestines. 

II.  Obstruction  by  Inflammatory    Tumefaction  of  the  Duodenum, 

OR   OF    the     lining     MEMBRANE     OF     THE     DUCT,    WITH     EXUDATION 
INTO   rrS    INTERIOR. 


CLASSIFICATION    OF    CAITSES.  335 


TABULAR  YIEW— continued. 

III.  Obstruction  by  Stricture  or  obliteratjon  of  the  duct. 

1.  Congenital  deficiency  or  obstruction  of  tlie  duct. 

2.  Stricture  from  peri-hepatitis. 

3.  Closure  of  orifice  of  duct  in  consequence  of  an  ulcer  in  the 

duodenum. 

4.  Stricture   from   cicatrisation    of  ulcers    in  the  bile-ducts. 

5.  Spasmodic  stricture  ? 

IV.  Obstruction    by    Tumours    closing    the    orifice    of    the   duct 

OR    GROWING   IN   ITS    INTERIOR. 

V.  Obstruction  by  Pressure  on  the  duct  from  without,  by 

1.  Tumours  projecting  from  the  liver  itself. 

2.  Enlarged  glands  in  the  fissure  of  tlie  liver. 

3.  Tumour  of  the  stomach. 

4.  Tumour  of  the  pancreas. 

5.  Tumour  of  the  kidney. 

t>.  Post-peritoneal  or  omental  tumour, 

7.  An  abdominal  aneurism. 

8.  Accumulation  of  feeces  in  bowels. 

9.  A  pregnant  uterus. 

10.   Ovarian  and  uterine  tumours. 


B.     JAUNDICE  INDEPENDENT  OF  MECHANICAL  OBSTRUCTION 
OF  THE  BILE-DUCT. 

I.  Poisons  in  the  Blood  interfering  with  the    normal  metamor- 
phosis OF  bile. 

1.  The  Poisons  of  the  various  specific  fevers  : 

a.  Yellow  fever. — b.  Bemittent  and  Intermittent  fevers.^ 
G.  Relapsing  fever. — d.  Typhus. — e.  Enteric  or 
Pythogenic  fever. — -f.  Scarlatina. — g.  '  Epidemic 
Jaundice.' 

2.  Animal  Poisons  : 

a.  Pyaemia.— &.  Snake-poison. 

3.  Mineral  Poisons : 

a.  Phosphorus. — 6.  Mercury. — c.  Copper. — c?.  Antimony, 
&c. 

4.  Chloroform  and  Ether. 

5.  Acute  Atrophy  of  the  liver  ? 

6.  Cirrhosis  and  other  foi'ms  of  Chronic  Atrophy  of  the  liver. 


33^  JAUNDICE  LF.CT.  X. 

TABULAR  YmW—coHtu,md. 

II.  Impaired  or  Deranged  Innervation  interfering  with  the  normal. 

METAMORPHOSIS    OF   BILE. 

1.  Severe  mental  emotions,  fright,  anxiety,  &e. 

2.  Concussion  of  the  brain. 

III.  Deficient    Oxygenation   of   the    Blood    interfering   with  the 

normal  metamorphosis  of  bile. 

IV.  Excessive  Secretion  of  bile,  more  op  which  is   absorbed  than 

can  undergo  the  normal  metamorphosis. 

Congestion  of  the  Liver  : 

a.  Mechanical. — b.  Active. — c.  Passive. 

V.  Undue  Absorption  of  bile    into  the  Blood    from    habitual  or 
protracted  constipation. 

I  shall  now  endeavour  to  describe  to  you  the  distinguishing 
characters  of  the  several  forms  of  jaundice  referred  to  in  the 
Table. 

A.   JAUNDICE   FRO.M   MECHANICAL   OBSTRUCTION   OF   THE 

BILE-DUCT. 

I.    OBSTRUCTION    BY    FOREIGN    BODIES    WITHIN    THE    DUCT. 

1.  Gall-stones  or  Inspissated  Bile. 

Gall-stones  are  among  the  most  common  causes  of  Jaundice 
from  Obstruction.  It  very  commonly  happens  that  the  gall- 
bladder is  found  full  of  concretions  after  death,  as  in  the 
specimens  I  show  you  here,  an^  yet  that  there  have  been  no 
symptoms  during  life  to  lead  to  any  suspicion  of  their  existence. 
Gall-stones  only  produce  jaundice  and  other  symptoms  when 
they  enter  the  bile-duct,  and  the  most  characteristic  symptoms 
are  those  which  are  produced  by  the  passage  of  the  concretions 
along  the  duct.  In  most  cases  where  there  are  the  symptoms 
of  gall-stones,  there  is  a  distinct  concretion  or  calculus ;  but 
similar  symptoms  occasionally  result  from  what  is  called 
inspissated  bile,  or  from  a  gritty  condition  of  the  bile.  It  is 
not  often  that  you  have  an  opportunity  of  proving  this  by  post- 
mortem examination,  although  it  is  a  fact  of  some  clinical 
importance,  inasmuch  as  it  accounts  for  some  of  those  cases 


lECT.  X.  FEOM    OBSTRUCTION    OP    BILE-DOCT.  337 

wliere  there  liave  been  the  symptoms  of  gall-stones,  but  where 
none  could  be  found  in  the  stools.  You  will  find,  however,  a  case 
related  by  Dr.  Handfield  Jones  in  the  fifth  volume  of  the  Patho- 
logical Transactions  (p.  150),  where  a  woman  died  of  universal 
jaundice  a  short  time  after  having  fractured  her  thigh  by 
a  fall,  and  where  the  lower  end  of  the  common  duct  was  found 
quite  plugged  up  with  '  a  sandy  matter  consisting  of  biliary 
pigment.'  You  know  also  that  all  the  phenomena  of  nephritic 
colic  may  be  produced  by  the  passage  of  lithic  acid  sand. 

The  jaundice  resulting  from  gall-stones,  as  a  rule,  is  not 
difficult  to  diagnose. 

1.  The  passage  of  a  gall-stone  along  the  common  duct, 
unless  it  be  a  very  small  one,  gives  rise  to  the  pain  known  as 
biliary  colic.  The  patient  is  often  forewarned  of  the  attack  by 
a  feeling  of  nausea  with  much  fl.atulence,  an  unusual  nervous 
excitability,  yawning,  or  shivering.  The  attack  usually  comes 
on  shortly  after  the  principal  meal, '  or  after  some  severe 
muscular  exertion  or  shaking  of  the  body.  Very  often  the 
patient  is  suddenly  seized  with  viole^it  pain,  but  more  commonly 
the  pain  is  moderate  at  its  onset  and  gradually  increases  in 
severity.  The  pain  starts  from  the  epigastrium  and  radiates 
to  both  hypochondria,  to  the  spine,  to  the  right  shoulder,  to  both 
shoulders,  to  the  left  alone,  or  to  the  neck,  but  never  downwards.'^ 
It  is  usually  of  two  sorts,  a  dull  aching  pain  which  is  constant ; 
and  an  acute  agonising  pain,  which  comes  and  goes  in  pa- 
roxysms, and  which  is  described  as  of  a  boriug,  tearing,  burn- 
ing, or  constricting  character.  The  latter  is  often  so  excru- 
ciating that  the  patient  will  bend  himself  double,  with  his  chin 
resting  on  his  bended  knees,  and  constantly  shift  his  position 
with  the 'object  of  obtaining  relief.  Women  who  have  borne 
many  children  will  tell  you  that  the  pains  of  childbirth  are 
nothing  in  comparison  to  those  of  biliary  colic.  Now  and  then, 
in  nervous  persons,  the  pain  excites  epileptiform  convulsions. 
The  paroxysms,  if  frequent  and  protracted,  induce  great  lassitude 
and  exhaustion,  the  face  being  pale,  the  pulse  slow,  and  the 
whole  body  covered  with  a  cold  sweat ;  occasionally  there  is  pro- 
found collapse,  which  in  rare  cases  has  been  fatal ;  and  in  three 

'  CuUen's  definition  of  biliary  colic  was  :  'Icterus,  cum  dolore  in  regione  epigas- 
trica,  acuto,  post  pastum  aucto,  et  cum  dejectione  concretionum  biliosarum.' 

-  I  cannot  confirm  Trousseau's  statement,  that,  although  it  more  genex-ally 
ascends,  '  the  pain  goes  down  into  the  abdomen,  in  some  cases  simulating  nephritic 
colic'     Clin.  Lect.  Syd.  Soc.  Ed.,  iv.  233.  ', 

Z  i 

\ 

V 


33o  JAUNDICE  LECT.  X. 

instances  I  have  known  an  attack  terminate  in  fatal  coma.' 
At  its  onset  the  pain  may  be  relieved  by  pressure  ;  but  after  it 
has  lasted  long  there  is  almost  always  some  tenderness  over 
the  fundus  of  the  gall-bladder,  which  persists  for  some  time 
after  the  paroxysm  has  subsided  and  is  a  useful  symptom  in 
diagnosis.  Occasionally  this  tenderness  is  acute  from  the  gall- 
bladder having  become  inflamed.  Trousseau  has  called  atten- 
tion to  the  circumstance  that  an  attack  of  hepatic  colic  is  some- 
times followed  by  an  intercostal  neuralgia,  distinguished  by 
tenderness  over  some  of  the  dorsal  spines.^  Lastly,  it  is  stated 
that  biliary  calculi  are  in  rare  instances  fimnd  in  the  fitools, 
without  there  having  been  any  symptoms  of  biliary  colic.^  Dr. 
Fagge  also  relates  the  case  of  a  man  who  died  of  hernia,  and 
who  had  previously  had  jaundice  unattended  with  pain;  his 
gall-bladder  contained  numerous  gall-stones,  and  the  common 
duct  was  dilated  so  as  to  admit  the  finger.'* 

2.  Rigors,  often  severe,  recurring  at  irregular  intervals,  but 
sometimes  periodically  almost  with  the  exactness  of  an  ague, 
are  not  uncommon  in  severe  and  protracted  cases,  and  are 
believed  to  depend  on  over-distension  of  the  gall-bladder  and 
bile-ducts.  In  reference  to  this  symptom  a  remarkable  specimen 
is  preserved  in  the  Pathological  Series  of  the  Royal  College  of 
Surgeons."'  It  is  that  of  a  large  oval  calculus  fitted  tightly  into 
the  end  of  the  common  bile-duct,  a  portion  of  it  projecting 
through  the  dilated  orifice  of  the  duct  into  the  duodenum.  The 
patient  from  whose  body  the  preparation  was  obtained  was  a 
very  large  woman,  aged  70,  who  for  nearly  six  months  had  been 
subject  to  spasmodic  pains  of  the  stomach,  coming  on  with 
shiverings  like  an  ague-fit,  which  lasted  for  half  an  hour  or  an 
hour,  and  were  succeeded  by  unusual  heat.  It  was  only  during 
the  last  month  of  life  that  vomiting  and  jaundice  had  set  in. 
Three  days  before  death  she  was  seized  with  an  unusually 
severe    attack  of  shivering  and   pain,  which  continued,  with 

'  The  first  case  was  a  lady  aged  76,  whose  urine  contained  much  albumen.  The 
second  was  a  lady  aged  8t,  whose  urine  also  contained  albumen  ;  she  recovered  from 
the  first  attiick  of  coma  ;  but  six  months  after  she  had  a  recurrence  of  biliary  colic, 
followed  by  coma  wliich  was  fatal.  The  third  case  was  a  Hindoo  lady,  aged  50, 
whose  urine  could  not  be  obtained. 

*  Op.  cit.  vol.  i.  p.  48-.'. 

*  A  case  in  point  is  related  by  Dr.  Senac  of  Vicliy.  l)u  Traitemcnt  des  Coliqncs 
h^patiques,  Paris,  1870,  p.  46. 

*  Guy's  IIosp.  Kcp.  1875,  vol.  xx. 

*  The  preparation  is  from  the  collection  of  Mr.  John  Howship,  and  is  numbond 
lis*). 


LECT.  X.  FEOM    OBSTRUCTION    OF    BILE-DUCT.  339 

scarcely  any  remission,  nntil  death.  In  Case  CXYII.,  although 
there  were  no  decided  rigors,  there  was  a  remarkable  period- 
icity in  the  attacks. 

3.  Vomiting  accompanies  the  paroxysms  in  most  cases  and 
is  often  frequent  and  severe,  the  patient  rejecting  all  food  that 
may  be  in  the  stomach  and  bringing  up  large  quantities  of  acid 
fluid.  Bilious  vomiting  indicates  that  the  common  bile-duct  is 
still  free.  The  act  of  retching  is  usually  followed  by  a  tem- 
porary alleviation  of  the  pain.  Very  often  there  is  frequent 
hiccup. 

4.  After  these  symptoms  have  lasted  from  twelve  to  twenty- 
four  hours,  jaundice  usually  appears,  and  if  the  obstruction  of 
the  bile-duct  continue  for  a  few  days  the  jaundice  becomes 
intense,  the  urine  being  loaded  with  bile-pigment,  giving  it  a 
deep  mahogany  hue,  and  the  fseces  containing  none.  At  the  com- 
mencement of  the  paroxysm,  before  the  appearaiice  of  jaundice, 
the  patient  often  passes  large  quantities  of  limpid  nervous  urine, 
and  occasionally  similar  urine  is  voided  on  some  particular 
occasion  during  the  persistence  of  jaundice,  although  that  which 
is  passed  immediately  before  and  after  contains  abundance  of 
bile.  The  occurrence  of  jaundice  may  be  said  to  clench  the 
diagnosis  of  the  nature  of  abdominal  colic,  but  it  is  not  inva- 
riably present  although  the  colic  be  hepatic.  If  the  stone  finds 
its  way  into  the  bowels  within  twenty-four  hours,  or  if  it  does 
not  get  beyond  the  cystic  duct,  or  if  its  form  is  so  angular  as 
not  entirely  to  block  the  flow  of  bile,  it  is  quite  possible  to  have 
biliary  colic  without  jaundice.  Many  patients  suffer  from 
repeated  attacks  of  what  is  put  down  as  gastralgia  or  cramp  in 
the  stomach,  without  any  jaundice,  but  whose  subsequent  his- 
tory leaves  little  doubt  that  the  atta,cks  have  been  due  to  gall- 
stones. In  these  cases  the  diagnosis  is  sometimes  assisted  by 
observing  that  the  attack  of  pain  is  followed  by  the  slightest 
yellow  tint  of  the  conjunctivse,  or  by  the  presence  of  bile- 
pigment  in  the  urine.  In  Case  CXVII.  the  patient  suffered 
from  severe  biliary  colic  daily  for  four  months  before  jaundice 
appeared,  the  stone,  from  its  great  size,  being  all  this  time 
detained  in  the  cystic  duct ;  and  Trousseau  mentions  a  case  in 
which  biliary  colic  occurred  repeatedly  during  four  years,  and 
then  for  the  first  time  jaundice  occurred.  There  is  also  good 
authority  for  the  statement  that  small  biliary  calculi  have  been 
found  in  the  stools  of  individuals  who  have  never  had  jaundice,' 

*  Trousseau,  op.  cit.  iv.  236. 
z  2 


340  JAUNDICE  LBCT.  X. 

but  sucli  cases  are  certainly  exceptional ;  and  I  ain  unable  to 
understand  the  statement  of  Wolff  tbat  25  out  of  45  patients 
observed  by  him  passed  through  the  whole  train  of  symptoms 
of  biliary  colic  without  jaundice,  the  concretions  being  found  in 
the  evacuations.'  The  duration  of  the  jaundice  will  vary  with 
the  number  and  size  of  the  stones,  but  usually  it  does  not  last 
longer  than  from  a  few  days  to  a  few  weeks.  It  is  nnt  very 
often  that  a  gall-stone  leads  to  permanent  jaundice,  for  if  it  suc- 
ceed in  escaping  from  the  cystic  duct,  where  its  presence  will 
not  cause  jaundice,  it  will  usually  find  its  way  through  the 
larger  common  duct.  Cases,  however,  are  occasionally  met 
with,  such  as  Case  CXVII.  where  permanent  and  even  fatal 
jaundice  has  been  caused  by  the  impaction  of  a  gall-stone.'^ 
But  although  the  jaundice  of  gall-stones  be  in  most  cases  of 
temporary  duration,  it  has  this  peculiarity,  that  it  is  liable  to 
recur  with  the  other  symptoms  already  referred  to  at  irregular 
intei'vals,  owing  to  some  of  the  concretions  not  escaping  from 
the  gall-bladder  during  the  first  attack,  or  to  fresh  ones  form- 
ing in  the  place  of  those  which  have  been  discharged.  The 
diagnosis  then  is  often  materially  assisted  by  the  patient  having 
had  a  similar  attack  on  some  former  occasion.  The  very  fact 
of  a  person  in  middle  or  advanced  life  having  had  several 
attacks  of  well-marked  jaundice,  with  distinct  intermissions, 
would  point  to  gall-stones  as  the  probable  cause.  At  the  same 
time  you  must  remember  that  when  a  large  calculus  has  forced 
its  way  through  the  natural  channels  of  the  bile,  they  will 
remain  permanently  dilated,  and  smaller  stones  may  be  after- 
wards voided  without  either  jaundice  or  pain.  According  to 
Sir  Thomas  Watson,  there  are  persons  who  get  rid  of  scores  of 
stones  in  this  way  during  the  course  of  their  lives. 

5.  The  jaundice  from  gall-stones  is  usually  unaccompanied 
by  fever  ;  there  is  no  increase  of  temperature,  and  the  pulse  is 
oftener  below  the  normal  standard  of  frequency  than  above  it. 
During  the  paroxysms  of  pain,  however,  increased  frequency  of 
pulse  and  a  temporary  rise  of  temperature,  even  when  the 
patient  is  shivering  and  the  extremities  feel  cold,  are  not  un- 
common ;  also,  if  the  pressure  of  the  calculus  has  induced  inflam- 

'  Virchow's  Arcliivcs,  vol.  xx.  pt.  2,  1861. 

*  In  the  Pathological  Transactions,  a  ca.se  of  fatal  jaundice  is  recorded  by  Dr. 
Handfield  Jones  (vol,  v.  p.-146),  where  the  hepatic  and  common  ducts  of  the  liver 
■were  obstructed  by  lari^e  calculi ;  and  another  is  reported  by  Dr.  J.  Wale  Hicks, 
where  the  cystic  duct  and  part  of  the  common  duct  were  occupied  by  a  large  gall- 
blone,  which  also  projected  into  the  gallbladder  (vol.  iv.  p.  126). 


XECT.  X.  FROM    OBSTEUCTION"    OF    BILE-DUCT.  341 

mation  or  ulceration  of  the  biliary  passages,  there  may  be  per- 
sistent or  intermittent  pyrexia  alter  the  pain  has  ceased, 
and  under  these  circumstances  fresh  attacks  of  pain  are  often 
followed  by  a  temporary  pyrexia  ending  in  perspiration.  Now 
and  then  it  haj)pens  that  a  gall-stone  in  one  of  the  biliary  ducts 
excites  paroxysms  of  intermittent  fever,  with  little  or  no  pain. 
These  paroxysms  may  be  more  or  less  periodic,  and  may  extend 
over  several  months  without  necessarily  indicating  pysemic  hepa- 
titis (see  p.  166),  the  patient  ultimately  recovering.  Charcot ' 
has  attributed  these  attacks  to  a  septic  poison,  the  product  of 
chemical  changes  in  the  bile  within  the  dilated  and  inflamed 
ducts  ;  but  more  probably  they  are  due  to  the  simple  irritation 
of  the  stone,  and  are  analogous  to  the  febrile  paroxysms  result- 
ing from  the  passage  of  a  catheter  along  the  urethra. 

After  the  paroxysms  of  biliary  colic  are  over,  the  urine 
usually  throws  down  copious  sediments  of  lithic  acid  or  lithates. 

6.  If  the  obstruction  of  the  bile-duct  persists  for  several  days 
there  will  often  be  found  a  slight  and  uniform  enlargement  of 
the  liver,  with  a  tender  pyriform  tumour  corresponding  to  the 
gall-bladder,  resulting  from  the  great  dilatation  of  the  biliary 
passages  by  the  accumulated  bile,  as  I  have  explained  to  you  in 
a  former  lecture  (p  160). 

7.  The  diagnosis  of  gall-stones  will  be  assisted  by  remem- 
bering the  circumstances  under  which  they  are  most  likely  to 
be  met  with. 

a.  Sex. — They  are  more  common  in  females  than  in  males 
(3  to  2). 

b.  They  are  chiefly  met  with  in  persons  of  middle  and 
advanced  life.  Of  395  cases  collected  by  Hein,  only  15  were 
under  twenty-five  years  of  age,  and  only  three  under  twenty. 
The  liability  to  the  formation  of  gall-stones  probably  increases 
with  advancing  age,  but  not  the  risk  of  biliary  colic.  Accord- 
ing to  Dr.  Senac  ^  of  Yichy,  who  has  paid  particular  attention  to 
this  subject,  hepatic  coli^  most  frequently  commences  about  the 
age  of  thirty-tive,  and  comparatively  rarely  after  titty.  You 
must  remember,  however,  that  gall-stones  are  occasionally  met 
with  in  early  life.  In  a  previous  lecture  I  have  detailed  to  you 
a  case  where  they  occurred  at  the  age  of  twenty-three  (Case 
LXXI.  p.  173)  :  and  rare  cases  have  been  observed  of  gall-stones 

'  Le  Progres  Med.  Aug.  1876. 

*  Du  Traitement  des  Coliques  liepatiques,  Paris,  1870,  p,  66. 


34-  JAUNDICE  LECT.  X. 

in  children  ^  and  even  in  young  infants.  In  the  first  volume  of 
the  Northern  Journal  of  Medicine  (p.  240)  you  will  find  a 
case  recorded  where  fatal  jaundice  in  a  new-born  babe  was  due 
to  obstruction  of  the  bile-duct  by  '  an  indurated  cord-like  plug 
of  insj^issated  bile  ; '  and  many  years  ago  Lieutaud  reported  the 
case  of  an  infant,  25  days  old,  in  whom  a  gall-stone  completely 
obstructed  the  orifices  of  the  hepatic  and  pancreatic  ducts.'^ 

c.  Climate. — In  warm  climates,  notwithstanding  the  liability 
to  hepatic  derangements,  gall-stones  are  very  rare. 

d.  Habits. — Gall-stones  are  particularly  common  in  persons 
of  stout  habit,  who  consume  large  quantities  of  rich  saccharine 
and  greasy  food  and  alcoholic  fluids,  and  who  at  the  same  time 
lead  sedentary  lives. 

e.  Social  Position. — From  what  has  been  stated  it  follows 
that  gall-stones  are  much  more  common  in  the  middle  and  upper 
classes  than  among  the  labouring  population  and  the  poor. 

/.  Associated  Diseases. — In  a  very  large  proportion  of  cases 
of  gall-stones  there  will  be  found  to  be  a  history  in  the  jjatient 
or  in  his  family  of  gout,  asthma,  urinary  gravel,  neuralgia, 
migraine,  or  urticaria.  This  is  a  point  upon  which  I  have  insisted 
in  my  Croonian  Lectures  on  Functional  Deraugements  of  the 
Liver,  and  in  which  the  extensive  experience  of  Dr.  Senac  is 
quite  in  accordance  with  mine. 

g.  Hereditary. — From  the  frequent  concurrence  of  gall-stones 
with  gout  and  allied  maladies,  it  is  not  to  be  wondered  at  that 
gall-stones  are  in  many  instances  hereditary.  We  constantly 
meet  with  several  members  of  the  same  family  who  have  suf- 
fered from  biliary  colic. 

h.  Exciting  Causes  of  Biliary  Colic. — Gall-stones  being  already 
in  the  gall-bladder,  an  attack  of  biliary  colic  is  often  determined 
by  an  overloaded  stomach,  menstruation,  a  fit  of  indigestion,  a 
sudden  strain,  a  fall,  driving  over  a  rough  road,  or  some  severe 
mental  emotion. 

8.  But  the  most  conclusive  proofs  of  jaundice  being  due  to 
gall-stones  is  finding  the  concretion  in  the  fa3ces.  It  is  not 
only  satisfactory  to  the  patient  to  see  the  stones,  but  their 
appearance  is  often  of  some  use  in  prognosis.  If  one  large 
globular  concretion  have  been  passed,  it  is  very  possible  that 
thepatient  may  not  be  further  troubled :  but  if  the  stone  be  marked 
by  several  flat  surfaces  or  facets,  such  as  I  show  you  here,  the 

'  TrouH.seau  mentions  a  case  in  a  girl  agod  nine. 
2  M6m.  do  I'Acad.  lioy.  de  Med.,  1847  xiii.  26-i. 


XKCT.  X.  FEOM    OBSTRUCTION    OF    BILE-DUCT.  343 

probability  is  tliat  there  are  several,  or  many,  more.  But  even 
wlien  all  the  symptoms  above  described  have  been  present  in  a 
marked  degree,  you  may  fail  in  finding  a  gall-stone  in  the  fseces. 
This  may  be  due  to  the  concretion  becoming  disintegrated  in 
the  bowel,  or  to  its  slipping  back  into  the  gall-bladder  instead 
of  into  the  duodenum,  or  to  the  obstruction  of  the  duct  having 
been  caused  by  inspissated  gritty  bile,  rather  than  by  a  distinct 
concretion ;  but  too  often  it  is  the  result  of  a  faulty  method  of 
search.  The  common  belief  is  that  gall-stones  are  lighter  than 
wa,ter,  and  that  therefore  if  v^ater  be  poured  on  the  faeces,  any 
gall-stones  present  v^ill  float ;  but  Sir  Thomas  Watson,  vv^ho 
recommended  this  method  in  the  earlier  editions  of  his  Lectures, 
added  : — '  I  never  but  once  succeeded  in  thus  catching  a  concre- 
tion in  the  evacuations  of  a  patient,  v^here  symptoms  had  led 
me  to  search  for  it.'  In  a  later  edition,  however,  he  says  that 
three  other  patients,  taught  how  to  search  for  them,  had  de- 
tected in  the  alvine  discharges  this  palpable  source  and  expla- 
nation of  their  previous  sufferings.*  The  truth  is  that  most 
gall-stones,  before  they  are  dried,  are  heavier  than  water,  in 
which  they  will  not  float ;  and  accordingly  the  plan  which  you 
have  seen  followed  in  the  wards,  and  which  is  the  only  reliable 
one,  is  to  pass  the  whole  evacuation  from  the  bowels  through 
muslin  or  a  sieve.-  Grall-stones  also  are  often  not  found  in  the 
fasces  owing  to  the  search  for  them  not  being  maintained  sufii- 
ciently  long.  Trousseau  relates  the  case  of  a  patient  who  never 
passed  the  stone  from  the  bowel  until  three,  four,  or  five  days 
after  the  termination  of  the  attack  of  biliary  colic.^  I  may  add 
that  a  German  physician,  WolfF,  who  took  the  pains  to  examine 
the  fseces  sometimes  for  months  after  an  attack  of  biliary  colic, 
never  failed  to  find  gall-stones  in  one  of  45  cases  of  biliary  colic 
occurring  in  his  practice  during  a  period  of  forty-three  years.^ 

2.  Hydatids,  Distomata,  and  Lumbrici  in  the  Bile-Duds. 

Hydatid  tumours  of  the  liver,  as  I  have  already  told  you 
(see  J)-  66),  occasionally  burst  into  the  bile-duct.  If  the 
tumour  contain  no  secondary  cysts,  its  fluid  contents  may  be 
discharged  through  the  bile-duct  into  the  duodenum,  and  the 
patient  may  get  well  without  any  marked  symptoms.  But  in 
most  cases  there  are  secondary  cysts  which  enter  and  obstruct 
the  bile-duct,  and  produce  all  the  symptoms  of  jaundice  from 

*  Lect.  on  Practice  of  Physic,  2nd  eel.  ii.  p.  527,  and  3rd  ed.  ii.  p.  655. 

2  Op.  cit.  vol.  iv.  p.  228.  ^  Virchow's  Archives,  vol.  sx.  pt.  1,  1861. 


3/]/^  JAUNDICE  LECT.  X. 

an  impediment  to  the  flow  of  bile.  In  a  former  lecture  I  have 
related  to  you  cases  where  this  occurred  (Cases  XXXII.  to 
XXXIV.  p.  112).  The  passage  moreover  of  the  hydatid  cysts 
along  the  bile-duct  may  give  rise  to  severe  paroxysms  of  pain, 
rigors,  and  vomiting,  and  in  fact  to  all  the  phenomena  of  the 
biliary  colic  resulting  from  gall-stones.  This  happened,  you 
will  remember,  in  a  marked  manner  in  Case  XXXIV.  From 
gall-stones,  however,  the  case  w^ould  be  distinguished — 

1.  By  there  being  the  physical  signs  of  hydatid  enlargement 
of  the  liver  alreadj^  described  to  you  (p.  55),  with  perhaps  a 
subsidence  of  the  swelling  on  the  occurrence  of  pain. 

2.  By  there  being  in  most  cases  symptoms  of  persistent 
fever,  a  quick  pulse  and  elevated  temperature,  in  addition  to 
those  of  biliary  colic.  When  the  hydatid  bursts  into  the  bile- 
duct,  not  only  do  vesicles  enter  the  duct,  but  bile  enters 
the  hydatid,  and  the  consequence  is  that  this  inflames  and  sup- 
purates and  causes  fever.  Where,  however,  as  in  Case  XXXIV., 
vesicles  continue  to  pass  along  the  bile-duct  long  after  the 
bursting  of  the  tumour,  there  may  be  biliary  colic  wdthout 
fever. 

3.  The  diagnosis  will  be  complete  on  detecting  hydatid 
vesicles  in  the  alvine  evacuations,  as  was  done  in  Case  XXXIV. 
(p.  116). 

In  those  rare  instances  to  which  I  have  already  (p.  66) 
directed  your  attention,  where  a  hydatid  tumour  appears  to  be 
developed  in  the  first  instance  in  the  bile-duct,  its  diagnosis 
will  probably  be  impossible. 

In  cases  of  extreme  rarity  the  Distoma  liepaticum,  or  liver- 
fluke,  which  is  so  common  in  the  livers  of  sheep,  has  been  found 
in  the  biliary  passages  of  the  human  subject,  but  its  presence 
does  not  appear  necessarily  to  obstruct  the  duct  and  cause 
jaundice.  In  Davaine's  great  work  on  Entozoa,  the  case  is 
related  of  a  girl,  aged  8,  who  died  in  the  hospital  at  Milan  of 
diarrhoea,  marasmus,  and  convulsions,  and  on  opening  whose 
body  there  was  found  a  pouch  containing  five  distomata  near 
the  termination  of  the  common  bile-duct.  This  patient  had 
suffered  from  all  the  symptoms  of  biliary  colic,  but  had  no 
jaundice.'  Some  years  ago  a  patient  died  in  this  (Middlesex) 
hospital,  whose  gall-bladder  was  found  to  contain  a  fluke.  The 
lining  membrane  of  the  gall-bladder  was  perfectly  white,  but  Dr. 
Budd,  who  relates  the  case,  does  not  state  whether  there  was 
'  Traiti  des  Entozoaires,  1860,  p.  2.52. 


LECT.  X.  FEOM    OBSTEUCTIOK'    OF    BILE-DUCT.  345 

any  obstruction  of  the  common  duct  or  jaundice.^  The  distoma 
in  the  sheep  causes  dilatation  and  catarrh  of  the  biliary  pas- 
sao-es,  with  atrophy  of  the  hepatic  tissue  and  great  anaemia,  but 
only  in  rare  cases  jaundice.  The  diagnosis  of  distomata  in  the 
bile-ducts  of  the  human  subject  could  only  be  arrived  at  in  the 
event  of  any  of  the  parasites  being  ejected  by  vomiting  or  in 
the  stools. 

There  are  also  not  a  few  instances  where  round  worms  have 
penetrated  the  orifice  of  the  bile-duct  and  caused  jaundice, 
with  biliary  colic,  vomiting,  and  all  the  symptoms  of  gall- 
stones.^ Some  years  ago  I  saw  in  the  Museum  of  the  General 
Hospital  at  Vienna  a  specimen  (No.  1312)  showing  the  common 
bile-duct  dilated  to  the  size  of  a  man's  thumb,  and  obstructed  by  a 
large  mass  of  round  Avorms.  Several  of  these  cases  have  proved 
fatal  suddenly  by  convulsions.  It  is  also  worth  noting  that  in 
many  of  these  cases  the  bowels  have  contained  a  number  of 
worms,  and  that  there  has  been  a  history  of  worms  being 
ejected  by  vomiting,  or  passed  per  anum.  It  is  by  such  an 
occurrence  alone  that  any  diagnosis  of  the  cause  of  the  jaundice 
could  be  arrived  at. 

3.  Foreign  Bodies  from,  the  Intestine. 

Foreign  bodies,  such  as  cherry-stones  and  currant-seeds, 
have  been  known  to  enter  the  bile-duct  from  the  intestine,  and 
to  give  rise  to  jaundice.  But  in  those  rare  cases  where  this  has 
happened,  it  is  probable  that  the  bile-duct  has  been  already 
dilated  by  the  passage  of  a  gall-stone.  Several  curious  cases 
are  on  record  where  the  nucleus  of  a  gall-stone  has  been  found 
to  be  a  dried-up  round  worm,  the  fragment  of  a  distoma,  a 
needle,  or  a  plum-stone. 

II.  JAUNDICE  FEOM  OBSTEUCTION  BT  mFLAMMATOET  TUilE- 
PACTION"  OF  THE  DUODENUM,  OE  OF  THE  LINING-  MEMBEANE 
OF    THE    BILE-DUCT,    WITH    EXUDATION    INTO    ITS    INTEEIOE. 

When  a  mucous  membrane  inflames,  it  becomes  swollen 
from  the  increased  amount  of  blood  in  its  vessels  and  from 

'  Dis.  of  Liver,  3rd  ed.  p.  494. 

-  Frerichs,  Dis.  of  Liver,  EngL  Transl.  ii.  p.  482;  Morehead,  Dis.  of  India,  1st 
ed.  1856,  ii.  165.  Davaine,  op.  cit.  p.  156  ;  and  particularly,  Bonfils,  '  Des  Lesions 
et  des  Phenomenes  pathologiques  determines  par  la  presence  des  Vers  Ascarides 
Lumbricoides  dans  les  canaux  biliaires,'  Archir.  Gen.  de  Med.,  Juin,  1858,  p.  661  ; 
and  Yinay,  '  Observ.  d'Ictere  generalise  tenant  a  la  presence  de  Lombrics  dans  les 
Toies  biliaires,'  Lyon  Med.,  1869,  i.  251. 


346  JAUNDICE  LECT.  X. 

oedematous  infiltration  of  the  submucous  tissue,  while  at  the 
same  time  the  secretion  from  the  surface  is  increased  in  quantity 
and  altered  in  quality.  If  these  changes  take  place  in  the 
mucous  membrane  lining  a  narrow  tube  like  the  bile-duct,  one 
can  easily  understand  that  the  passage  through  it  should  be 
blocked  up,  and  this  in  fact  is  what  often  happens.  Catarrhal 
inflammation  is  one  of  the  most  common  causes  of  mechanical 
jaundice,  and  is  certainl}'^  the  most  common  cause  of  jaundice 
in  young  persons.  To  this  cause  are  referable  most  of  the  cases 
commonly  described  as  '  simple  jaundice.'  Its  symptoms  and 
the  circumstances  under  which  it  occurs  have  been  full}''  de- 
scribed to  you  in  a  former  lecture  (p.  152).  In  a  large  number 
of  cases,  as  I  told  you,  the  inflammation  commences  in  the 
duodenum  and  sj)reads  up  the  bile-duct,  and  sometimes  the 
duodenal  orifice  of  the  duct  may  be  found  effectually  blocked  up 
by  the  tumid  mucous  membrane  of  the  duodenum  or  by  a  plug 
of  viscid  mucus,  without  the  inflammation  having  extended 
further  up  the  duct. 

In  diagnosing  the  causes  of  jaundice,  it  is  important  to  re- 
member that  inflammation  of  the  biliary  passages  may  be  caused 
by  gall-stones,  and  that  thus  the  symptoms  of  these  two  causes 
of  jaundice  may  coexist;  or  it  is  possible  that  inflammation  of 
the  biliary  passages  may  be  excited  by  gall-stones  which  have 
never  produced  biliary  colic.  In  the  case  of  J.  K.  (Case  LXV. 
p.  159)  you  will  remember  that  the  inflammation  of  the  biliary 
passages  seemed  to  be  excited  by  gall-stones,  which  were  found 
in  the  gall-bladder  and  in  the  bile-ducts,  and  yet  that  the  most 
careful  enquiry  failed  to  elicit  any  history  of  biliary  colic.  The 
paroxysmal  pain  is  caused  by  the  passage  of  the  calculus  aloruf 
tlie  dud.  Concretions  which  never  leave  the  gall-bladder  may 
also  excite  inflammation  of  its  lining  membrane,  and  this  may 
spread  to  the  bile-ducts,  but  will  not  give  rise  to  biliary  colic. 

Lastl}^  it  must  be  remembered  that  the  bile-duct  may  be 
easily  closed  by  a  catarrhal  swelling,  which,  as  in  the  case  of 
oedema  of  the  glottis,  could  not  be  demonstrated  after  death. 

III.    JAUNDICE    FROM    OBSTRUCTION    TO    THE     FLOW    OF    BILE    BY 
STRICTURE    OR  OBLITERATION    OF    THE    BILE-DUCT. 

1 .  Comjenital  Deficiency  or  Obstruction  of  the  Duct. 

I  have  already  told  you  that  in  the  majority  of  cases  of  the 
so-called  icterus  neonatorum  the  yellow  colour  of  the  skin  is  not 


LKCT.  X.  FROM    OBSTRUCTION    OF    BILE-DUCT.  34/ 

jaundice  at  all  (p.  312).  At  tlie  same  time  infants  are  liable  to 
real  jaundice,  which  is  sometimes  a  serious  symptom.  It  may, 
as  we  have  seen,  depend  upon  a  plugging  of  the  duct  with 
inspissated  bile  (p.  342),  and  then  there  may  be  some  hope  of 
the  obstruction  giving  way  and  of  the  child  recovering  ;  or,  as  I 
shall  have  occasion  to  explain  to  you  in  another  lecture,  it  may 
depend  on  deficient  oxygenation  of  the  blood  interfering  with 
the  normal  metamorphosis  of  bile.  At  other  times  it  has  a 
pygemic  origin,  and  is  associated  with  peritonitis,  or  with 
phlebitis  of  the  umbilical  vein ;  and  lastly  it  may  be  due  to  a 
congenital  closure,  obliteration,  or  absence  of  the  bile-duct,  no 
trace  of  it  remaining  except  a  little  areolar  tissue  between  the 
hepatic  artery  and  portal  vein.  The  gall-bladder  in  these  cases 
is  extremely  small  and  collapsed,  and  sometimes  it  also  is 
absent;  but  in  the  duodenum  the  opening  of  the  pancreatic 
duct  may  be  found  as  usual.  Cases  of  this  sort  have  been  re- 
corded or  collected  by  Dr.  A.  D.  Campbell,  in  the  Northern 
Journal  of  Medicine  for  1844,  by  Dr.  Wilks,  in  the  13th 
volume  of  the  Pathological  Transactions  (p.  119),  by  Dr. 
West  in  his  standard  work  on  the  Diseases  of  Infancy  and 
Childhood  (5th  ed.  p.  605),  and  more  recently  by  Dr.  Binz  of 
Bonn,  in  Yirchow's  Archives.^  In  not  a  few  of  the  cases  which 
have  been  recorded,- there  has  been  evidence  of  intra-uterine 
peri-hepatitis,  and  strange  to  say,  notwithstanding  the  rarity 
of  the  malformation,  many  writers  have  referred  to  several  in- 
stances of  it  occurring  in  the  same  family.  These  considera- 
tions suggest  the  desirability  of  enquiry,  whether  these  malfor- 
mations be  not  sometimes  one  of  the  results  of  peri-hepatitis 
from  hereditary  syphilis. 

The  following  case  (Case  CXXI.)  came  under  my  own  notice 
a  few  years  ago,  in  the  out-patient  department  of  this  (Middle- 
sex) hospital. 

Jaundice  from  this  cause  may  be  recognised  by  the  following 
characters  : — 

a.  The  jaundice  appears  within  a  few  days  of  birth,  and 
gradually  increases  in  intensity.  The  conjunctivse  as  well  as 
the  skin  are  yellow. 

h.  The  motions  are  white,  and  the  urine  leaves  a  yellow  stain 
on  the  clothes. 

'  Zur  Kenntniss  des  todtlichen  Icterus  der  Neugebornen  aus  Obliteration  der 
Gallengange.  Archiv  f.  path.  Anat,  und  Physiol.  un«i  f.  klinische  Medicin,  Berlin 
1866,  vol.  XXXV.  p.  360.  Eeferences  to  several  other  papers  on  the  subject  will  be 
found  in  Dr.  West's  work  quoted  above;    also  Glasgow  Med.  Journ.  Jan.  1876,  p.  U. 


348  JAUNDICE  XECT.  X. 

c.  In  most  cases  tliere  have  been  observed  hBemorrliages 
from  the  umbilicus  (often  fatal),  from  the  bowels,  beneath  the 
skin,  and  in  other  parts  of  the  body,  as  in  Case  CXXI. 

d.  At  tirst  the  child  may  appear  strong  and  healthy,  but 
very  soon  progressive  atrophy  sets  in,  attended  often  with 
vomiting  and  diarrhoea,  and  death  usually  occurs  within  a  few 
months  of  birth.  In  one  of  Dr.  Campbell's  cases,  and  in  another 
related  by  Dr.  West,  the  infant  lived  for  six  months. 

2.  Stricture  of  the  Bile-Duct  from  Peri-hepatitis. 

In  peri-hepatitis  the  lymph  which  is  thrown  out  becomes  after 
a  time  organised,  and  causes  thickening  of  the  capsule  and 
firm  fibrous  bands  of  adhesion  connecting  the  liver  to  surround- 
ing parts.  Now  and  then  it  happens  that  the  new  areolar 
tissue,  which  is  formed  in  this  way  in  the  portal  fissure,  exerts 
a  constricting  effect  on  the  bile-duct  and  sometimes  also  on 
the  portal  vein,  and  the  result  is,  in  the  one  case  jaundice,  and 
in  the  other  ascites,  with  the  other  signs  of  portal  obstruction 
already  referred  to  (see  pp.  275-284).  You  will  find  a  case  of  this 
sort  related  by  Frerichs.'  It  will  often  be  difficult  to  recognise 
during  life  this  cause  of  jaundice,  but  the  following  characters 
may  sometimes  be  of  assistance  in  diagnosis : 

1.  A  history  of  some  of  the  usual  causes  of  peri-hepatitis, 
such  as  simple  ulcer  of  the  stomach,  iufiammation  of  the  right 
pleura,  general  peritonitis,  other  diseases  of  the  liver,  and 
especially  constitutional  syphilis. 

2.  An  antecedent  history  of  the  symptoms  of  peri-hepatitis, 
and  more  particularly  of  acute  pain  and  tenderness  in  the  right 
hypochondrium  with  more  or  less  pyrexia. 

3.  The  concurrence  of  symptoms  of  chronic  atrophy  of  the 
liver  and  signs  of  portal  obstruction  (seep.  277). 

4.  The  absence  of  any  history  of  biliary  colic,  or  of  any 
indications  of  cancer. 

5.  The  fact  of  the  jaundice,  when  once  it  appears,  being 
permanent,  not  intermittent. 

3.  Closure  of  Orifice  of  the  Duct  in  consequence  of  an  Ulcer  in 
the  iJuodenum. 

This  is  another  cause  of  mechanical  jaundice  of  which  the 
recognition  during  life  is  often  very  difficult.  Simple  ulcers, 
like  those  of  the  stomach,  occasionally  form  in  the  duodenum 

'  Op.  cit.  vol.  i.  p.  151. 


I.ECT.  X.  FEOM    OBSTRUCTION    OF    BILE-DUCT.  349 

and  may,  like  them,  end  in  lisemorrliage  or  perforation.  Oc- 
casionally it  happens  that  one  of  these  ulcers  is  situated  at  the 
part  of  the  duodenum  corresponding  to  the  opening  of  the  bile- 
duct,  and  this  becomes  obstructed  by  inflammatory  products 
which  are  apt  to  become  organised,  and  then  the  obstruction  is 
permanent.  A  like  result  may  ensue  from  the  end  of  the  duct 
being  involved  in  the  cicatrix  of  a  duodenal  ulcer,  as  happened 
in  the  case  of  James  B.,  who  died  in  this  (Middlesex)  hospital 
(Case  CXXII.).  In  the  diagnosis  of  this  cause  of  obstruction 
we  must  be  guided  by — 

1.  The  circumstance  of  the  jaundice  and  other  signs  of 
obstruction  of  the  bile-duct  being  preceded  by  the  symptoms  of 
ulcer  of  the  duodenum,  such  as  pain  felt  only  two  or  three  hours 
after  a  meal,  when  the  food  is  passing  from  the  stomach  into  the 
duodenum,  with  perhaps  occassional  attacks  of  sudden  and 
profuse  haemorrhage  from  the  stomach  or  bowels.  These  sym- 
ptoms, however,  are  often  absent  in  cases  of  ulcer  of  the 
duodenum,  which  may  indeed  run  such  a  latent  course  that 
its  existence  is  not  suspected  until  the  occurrence  of  fatal  per- 
foration.' 

2.  In  any  case  of  persistent  and  intense  jaundice  with 
complete  disappearance  of  bile  from  the  motions,  the  very 
absence  of  all  symptoms  antecedent  to  those  of  obstruction  of 
the  bile-duct,  while  at  the  same  time  there  is  no  evidence  of  a 
tumour,  of  ascites,  or  of  the  cancerous  cachexia,  and  no  history 
of  biliary  colic,  will  lend  some  probability  to  the  view  that  the 
cause  of  obstruction  is  a  duodenal  ulcer.  There  is,  however,  a 
source  of  fallacy  in  the  fact  that  an  ulcer  of  the  duodenum,  near 
the  opening  of  the  common  duct,  has  been  known  to  induce 
attacks  of  spasmodic  abdominal  pain  followed  by  jaundice.  In 
such  a  case  an  absolute  diagnosis  from  gall-stones  would  be 
impossible  ;  for  although  the  occurrence  of  the  paroxysms  im- 
mediately after  obvious  errors  in  diet,  or  in  conjunction  with 
the  symptoms  of  duodenal  ulcer  already  referred  to,  might 
point  to  this  as  the  probable  cause,  yet  duodenal  ulcer,  as  I  have 
told  you,  is  often  a  remarkably  latent  disease.  Fortunately 
cases  of  this  sort  are  so  rare  as  not  often  to  embarrass  the 
diagnosis. 

'  In  the  ninth  volume  of  the  Pathological  Transactions  (p.  197),  I  have  recorJed 
the  case  of  a  large  finely  developed  man  who  died  suddenly  of  peritonitis,  from  a 
perforating  ulcer  of  the  duodenum,  and  who  up  to  the  time  of  his  fatal  attack  had 
enjoyed  excellent  health,  and  had  never  suffered  from  vomiting  or  even  pain  after 
meals.  Similar  cases  have  been  related  by  Dr.  Budd,  in  his  Lectures  on  Diseases  of 
the  Stomach  (p.  149),  and  by  other  writers.. 


350  JAUNDICE  I.ECT.  X. 

4.  Stricture  from  Cicatrisation  of  Ulcers  in  the  Bile-Ducts. 

Stricture  or  obliteration  of  the  common  bile-duct  may  result 
from  cicatrisation  of  ulcers  on  its  inner  surface,  produced  by  the 
pressure  and  irritation  of  gall-stones,  or  independent  of  gall- 
stones, and  the  impediment  to  the  flow  of  bile  will  cause  jaun- 
dice. When  a  gall-stone  becom.es  impacted  in  the  common 
duct,  it  may  lead  to  adhesions  and  permanent  closure  of  the 
duct  below  it;  at  other  times  the  gall-stone  after  causing 
ulceration  escapes,  and  a  stricture  forms  during  the  cicatrisation 
of  the  ulcer;  and  occasionally  ulceration  of  the  bile-duct,  with 
subsequent  cicatrisation,  appears  to  be  independent  of  gall- 
stones.^ Most  writers  on  jaundice  have  referred  to  stricture 
of  the  bile-duct  as  a  possible  cause,  and  you  will  find  two  cases 
in  illustration  recorded  in  the  Pathological  Transactions,  one 
by  Dr.  Bristowe,^  and  the  other  by  Mr.  Holmes.^  In  the  former 
the  stricture  was  situated  in  the  duct  of  the  left  lobe,  and  in 
the  latter  it  was  in  the  common,  before  its  junction  with  the 
cystic,  duct.  In  both  cases  the  stricture  exactly  resembled  an 
urethral  stricture,  and  was  attended  by  thickening  of  the  parietes 
with  evident  marks  of  cicatrisation  ;  in  both  there  was  great 
dilatation  of  the  ducts  on  the  liver  side  of  the  constriction  ;  and 
in  both  there  was  jaundice.  Gall-stones  were  found  in  neither 
case,  and  in  Mr.  Holmes's  case  there  was  no  history  of  biliary 
colic,  or  of  any  previous  attack  of  jaundice. 

As  to  the  distinguishing  characters  of  this  jaundice  it  may 
be  said — 

1.  That  in  many  cases  there  will  be  an  antecedent  history  of 
the  passage  of  gall-stones.  In  all  cases  where  the  symptoms  of 
gall-stones  are  followed  by  permanent  jaundice  without  pain  it 
may  be  suspected  either  that  the  gall-stone  has  become  firmly 
impacted,  or  that  it  has  produced  an  organic  stricture  or  closure 
of  the  duct. 

2.  That  when  the  ulceration  of  the  bile-duct  is  indepen- 
dent of  gall-stones  the  diagnosis  will  usually  be  doubtful.  The 
symptoms  of  ulceration  of  the  bile-duct   have   not   yet  been 

'  Ulceration  of  the  biliary  passages,  independent  of  gall-stones,  is  occasionally 
found  after  death  from  pythogenic  or  enteric  fever.  In  my  work  on  the  Continued 
Fevers  of  Great  Britain  (2nd  ed.  pp.  564,  630),  1  have  related  a  case  of  enteric  fever 
•where  fatal  peritonitis  was  excited  hy  a  perforating  ulcer  of  the  gall-bladder. 
I'rerichs  (op.  cit.  ii.  4.')6)  refers  to  a  case  reported  by  Dance,  where  the  ductus 
communis  was  found  ulcerated,  independently  of  cither  gall-stones  or  of  a  specific 
fever.  '•'  Vol.  ix.  p.  22.  '  Vol.  xi.  p.  130. 


T.ECT.  X.  PEOM    OBSTRUCTION    OF    BILE-DUCT.  35 1 

carefully  recorded  and  analysed,  but  you  will  rememter  that 
this  lesion  sometimes  gives  rise  to  pyaemia  with  multiple  ab- 
scesses in  the  liver  (see  pp.  166  and  341)  ;  and,  independently 
of  pyssmia,  it  is  probable  that,  as  in  Mr.  Holmes's  case  above 
referred  to,  the  ulceration  will  be  ushered  in  with  chilliness 
and  rigors,  and  be  accompanied  by  pain  or  uneasiness  in  the 
hepatic  region,  and  pyrexia  with  great  variations  of  temperature. 
From  these  symptoms  I  have  diagnosed  ulceration  of  the  bile- 
ducts  in  one  or  two  cases  of  jaundice,  but  I  have  had  no  oppor- 
tunity of  verifying  the  diagnosis. 

5.  Spasmodic  Stricture  of  the  Bile-Duct. 

When  the  common  bile-duct  becomes  constricted  or  obli- 
terated from  any  of  the  four  causes  just  mentioned,  the  jaundice 
is  deep  and  permanent,  there  is  progressive  emaciation,  and  death 
sooner  or  later  is  the  result.  But  it  was  formerly  imagined  • 
that  temporary  jaundice  might  result  from  spasmodic  constric- 
tion of  the  duct,  constituting  what  was  called  icterus  spasmodicus  ; 
and  indeed  all  cases  of  jaundice  where  no  mechanical  obstruc- 
tion to  the  flow  of  bile  could  be  found  after  death  were  at  one 
time  explained  in  this  way.  The  contractility  of  the  bile-ducts 
has  been  demonstrated  by  experiment,  when  they  have  been 
mechanically  irritated  or  galvanised  in  an  animal  just  dead,  and 
it  is  very  possible  that  during  life  the  passage  of  irritating  bile 
may  cause  spasmodic  contraction  of  the  duct  with  severe  pain, 
in  the  same  way  as  spasm  of  the  bowel  is  believed  to  cause 
colic,  and  spasm  of  the  bronchi,  asthma.  It  is  very  doubt- 
ful, however,  if  jaundice  ever  results  from  spasmodic  contraction 
of  this  sort.  I  have  already  told  you  (p.  314)  that  even  me- 
chanical obstruction  of  the  duct  takes  a  day  or  longer  to 
produce  jaundice  of  the  integuments,  and  it  is  difficult  to 
conceive  that  a  spasmodic  stricture,  independent  of  any 
mechanical  obstruction,  could  last  sufficiently  long  to  produce 
a  like  result.  I  have  also  explained  to  you  how  catarrhal 
obstruction  of  the  bile-duct  may  cease  with  death,  and  how 
jaundice  may  be  developed  independently  of  any  impediment 
to  the  flow  of  bile,  so  that  it  is  unnecessary  to  have  recourse  to 
the  theory  of  spasm  to  account  for  those  cases  where  no  me- 
chanical obstruction  of  the  bile-duct  can  be  found  after  death. 

'  See,  for  example,  Saunders's  Treatise  on  the  Structure,  Economy,  and  Diseases  ct 
the  Liver,  and  on  Bile  and  Biliary  Concretions,  3rd  ed.  1803,  p.  100  ;  and  Sir 
Thomas  Watson's  Lectures  on  Medicine,  3rd  ed.  yoI.  ii.  p.  567. 


352  JAUNDICE  LECT.  X. 

IV.    OBSTRUCTION    BY    TUMOURS  CLOSING    THE    ORIFICE    OF    THE 
DUCT    OR    GROWING    IN    ITS    INTERIOR. 

The  channel  or  opening  of  the  bile-duct  is  liable  to  become 
obstructed  by  cancerous  and  other  growths  in  the  duodenum  ; 
by  tumours  in  the  pancreas,  gall-bladder,  or  adjacent  parts, 
penetrating  the  part  of  the  duodenum  where  the  duct  opens  or 
the  duct  itself  in  any  part  of  its  course ; '  or,  in  rare  cases,  by 
growths  originating  in  the  walls  of  the  bile-ducts  themselves. 
In  Case  CXXIV.  there  was  a  cancerous  tumour  in  the  head  of 
the  pancreas,  but  the  cause  of  the  jaundice  was  an  independent 
growth  in  the  bile-duct.  Another  case  of  jaundice  from  ob- 
struction of  the  bile-duct  by  a  tumour  developed  in  its  walls  is 
recorded  by  Dr.  Bristowe,  in  the  ninth  volume  of  the  Patho- 
logical Transactions  (p.  220).  Case  CXXVI.  is  an  example  of 
cancer  of  the  pancreas,  involving  in  its  growth  the  gall-bladder 
and  the  bile-duct ;  and  you  will  find  two  similar  cases  recorded 
by  Frerichs,  in  which  the  cancer  had  invaded  the  duodenum 
and  obstructed  the  orifice  of  the  bile-duct.''^  The  chief  characters 
on  which  we  must  rely  for  the  diagnosis  of  this  cause  of  jaun- 
dice are  as  follows  : — 

1.  Before  the  jaundice  appears,  the  patient  usually  com- 
plains for  some  weeks,  or  longer,  of  pain,  more  or  less  severe, 
and  sometimes  lancinating,  in  the  region  of  the  duodenum. 
This  pain  continues  after  the  appearance  of  jaundice,  and  is 
usually  aggravated  two  or  three  hours  after  taking  food. 

2.  In  most  cases  there  are  nausea  and  a  tendency  to  vomit, 
especially  after  food. 

3.  Hsemorrhage  from  the  stomach  or  bowels  is  occasionally 
met  with  when  there  is  cancerous  ulceration  of  the  duodenum. 

4.  In  some  cases  a  hard  and  tender  tumour  can  be  felt  more 
or  less  distinctly,  on  careful  examination  through  the  abdominal 
parietes. 

5.  The  jaundice,  when  once  it  appears,  gradually  increases 
in  intensity  and  lasts  till  death,  which,  it  is  important  to  add, 
occurs  in  most  cases  within  four  or  five  months  of  the  first  ap- 
pearance of  yellowness  of  the  skin.  The  very  circumstance  of 
jaundice  lasting  in  any  case  longer  than  six  months  would  be 

'  In  the  Piithological  Transactions  (vol.  xxiv.  p.  103)  Dr.  Sydney  Con  plane!  has 
reported  a  case  where  a  cancerous  ulcer  of  the  duodenum  just  beyond  the  pylorus, 
invaded  the  gall-bladder,  and  from  this  the  cystic  and  hepatic  duct,  so  as  to  cause 
jaundice  without  implicating  the  common  bile-duct. 

*  Op.  cit.  vol.  i.     Cases  VI.  and  VII. 


LECT.  X.  FROM    OBSTRUCTION    OF    BILE-DUCT.  353 

an  argument  against  its  being  due  to  a  cancerous  tumour 
originating  in  the  wall,  or  encroacliing  upon  the  channel  of  the 
bile-duct.  This  rule,  however,  is  not  without  exceptions,  of 
which  we  had  a  remarkable  instance  in  the  case  of  William 

M (Case  CXXVII.). 

6.  Both  before  and  after  the  appearance  of  jaundice  there 
will  be  progressive  emaciation  and  debility  and  the  other 
phenomena  of  the  cancerous  cachexia.  The  diagnosis  may  also 
sometimes  be  aided  by  indications  of  cancer  in  other  parts  of 
the  body,  or  by  a  family  history  of  cancer. 


V.    OBSTEUCTIOISr    BY    PRESSURE  ON    THE    DUCT  FROM  WITHOUT. 

There  are  various  tumours  and  other  morbid  conditions  of 
the  abdomen,  which  may  compress  the  bile-duct  from  without, 
so  as  to  interrupt  the  flow  of  bile  and  cause  jaundice.  The 
duration  of  the  jaundice  and  the  prognosis  will  depend  on  the 
compressing  cause  in  each  case. 

1 .   Tumour  projecting  from  the  Liver  itself. 

Diseases  of  the  glandular  tissue  of  the  liver,  even  when  far 
advanced,  do  not  as  a  rule  cause  jaundice.  We  have  already 
seen  that  the  secreting  structure  may  be  almost,  if  not  quite, 
destroyed,  without  any  jaundice  resulting.  Outgrowths,  how- 
ever, from  diseased  livers  may,  like  other  tumours,  comjjress 
the  bile-duct  and  interfere  with  the  flow  of  bile,  and  thus  it  is 
that  jaundice  may  appear  in  cancer  of  the  liver,^  hydatids,^ 
tropical  abscess,  &c.,  where  as  a  rule  it  is  absent.  The 
diagnosis  of  the  cause  of  jaundice  in  these  cases  must  be  based 
on  the  presence  of  the  characters  of  the  primary  disease  of  the 
liver,  which  have  been  described  to  you  in  previous  lectures. 

2.  Enlarged  Glands  in  the  Fissure  of  the  Liver. 

The  lymphatic  glands  in  the  fissure  of  the  liver  when  en- 
larged from  cancerous,  waxy,  lymphomatous,^  or  tubercular 
deposit  may  compress  the  bile-duct  so  as  to  narrow  or  obstruct 

'  See  a  case  reported  by  Dr.  Bristowe,  in  tlie  ninth  volume  of  the  Pathological 

Transactions,  p.  223,  Case  IV. 

^  In  the  multilocular  hydatid  of  the  liver  jaundice  is  usually  present.    (See  p.  241.) 
^  In  the  20th  volume  of  the  Pathological  Transactions  I  have  recorded  the  case 

of  a  girl  aged  13,  who  had  persistent  jaundice  from  compression  of  the  bile-duct  by 

enlarged  lymphomatous  glands  in  the  portal  fissure. 

A  A 


354  JAUNDICE  LBCT.  X. 

its  channel  and  cause  jaundice.'  In  a  large  proportion  of  the 
cases  of  cancerous  or  waxy  liver  where  jaundice  is  observed,  it 
is  produced  in  this  way.      I  may,  for  instance,  recall  to  your 

recollection  the  case  of  Hannah  C (Case  LXXXV.,  p.  2J6), 

who  died  of  cancer  of  the  liver  and  ovary,  and  whose  jaundice 
was  due  to  compression  of  the  bile-duct  by  a  mass  of  enlai'ged 
glands  and  dense  areolar  tissue  in  the  portal  fissure.  In  cases 
also  of  primary  cancer  of  the  stomach  cancerous  matter  is  often 
infiltrated  into  the  lesser  omentum,  and  may  compress  the  bile- 
duct  and  produce  jaundice.  The  recognition  during  life  of 
the  cause  of  obstruction  of  the  bile-duct  in  these  cases  must 
depend  mainly  on  : — 

1.  The  signs  and  symptoms  of  waxy  disease  or  cancer  of 
the  liver,  which  I  have  described  to  you  in  former  lectures,  or  of 
cancer  of  the  stomach,  or  general  tuberculosis,  or  lymphoma. 

2.  The  co-existence  in  most  cases  of  ascites,  owing  to  the 
pressure  being  exerted  on  the  portal  vein  as  well  as  on  the  bile- 
duct  (see  Case  LXXXVII.,  p.  219). 

3.  Tumour  of  the  Stomach. 

A  cancerous  tumour  of  the  pyloric  end  of  the  stomach  may 
cause  jaundice  by  mere  compression  of  the  bile-duct.  More 
commonly  the  duct  is  compressed  by  secondary  cancerous 
deposits  in  the  lesser  omentum,  or  in  the  glands  of  the  portal 
fissure.  The  cause  of  the  jaundice  in  such  a  case  may  be 
recognised : — 

1.  By  the  fact  of  its  being  preceded  and  accompanied  by 
the  ordinary  symptoms  of  cancer  of  the  pylorus,  and  more 
particularly  by  pain  and  vomiting  after  food,  coffee-ground 
vomit,  and  rapid  emaciation."^ 

2.  By  the  situation  of  the  tumour,  and  by  the  fact  of  its 
being  often  accompanied  by  great  dilatation  of  the  stomach, 
distinguishable  thiough  the  abdominal  parietes. 

4.  Tumour  of  the  Pancreas. 

A  tumour  of  the  pancreas  may  not  only,  as  we  have  seen, 
invade  the  duodenum  and  close  the  orifice  of  the  bile-duct,  or 
penetrate  and  obstruct  the  duct  at  different  parts  of  its  course  ; 
but,  when  large,  it  may  compress  the  duct  from  without  so  as  to 

'  See  a  case  recordeJ  by  Dr.  ITandficld  Jones  in  the  Pathological  Transactions, 
Tol.  V.  p.  149. 

'•'  See  a  case  reporte  I  by  Dr.  Bristowe,  in  the  ninth  volume  of  the  Pathological 
Transactions,  p.  22.'>,  Case  VII. 


LECT.  X.  FEOM    OBSTRUCTION    OP    BILE-DUCT.  355 

constrict  or  obliterate  its  clia.nnel.  The  symptoms  of  this  form 
of  obstruction  of  the  bile-duct  will  not  differ  much  from  those 
of  obstruction  from  a  cancerous  tumour  of  the  duodenum  (see 
p.  352),  viz.  :— 

1.  Pain  referred  to  the  situation  of  the  pancreas. 

2.  ]SFa,usea  and  tendency  to  vomit. 

3.  A  distinct  hard  tumour  often  appreciable  at  the  seat  of 
pain. 

4.  Jaundice  permanent  until  death. 

5.  Eapid  emaciation  and.  other  indications  of  the  cancerous 
cachexia. 

6.  The  passage  in  some  cases  of  a  large  quantity  of  fatty 
matter  in  the  stools  (see  p.  317). 

The  phenomena  arising  from  obstruction  of  the  bile-duct  by 
a  cancerous  tumour  in  the  pancreas  may  be  closely  simulated 
by  an  abscess  in  the  pancreas,  secondary  to  a  simple  ulcer  of 
the  duodenum,  which  involves  and  obstructs  the  opening  of  the 
bile-duct  in  the  manner  already  described  (see  p.  349).  This 
appears  to  me  to  have  been  the  pathology  of  a  case  recorded  by 
Dr.  Gr.  Harley,  in  the  thirteenth  volume  of  the  Pathological 
Transactions  (p.  119). 

5-.   Tumours  of  the  Kidneys. 

Great  enlargement  of  the  kidneys,  according  to  Dr.  Copland,^ 
may  cause  jaundice  by  the  pressure  exerted  by  the  tumour  on 
the  bile-duct ;  but  jaundice  from  this  cause  must  be  extremely 
rare,  as  I  have  been  unable  to  iind  a  case  in  illustration  re- 
corded in  the  Pathological  Transactions,  or  elsewhere,  and  I 
have  frequently  known  the  kidneys  enormously  enlarged  from 
various  causes  without  any  jaundice  resulting.  In  a  former 
lecture  I  called  your  attention  to  a  case  where  there  was  an 
enormous  cystic  tumour  of  the  right  kidney  (Case  YIII.,  p.  27), 
containing  at  least  200  oz.  of  fluid :  and  I  show  you  here  a 
cancerous  tumour  of  the  left  kidney,  from  a  boy  aged  8,  which 
weighed  496  oz.  and  filled  almost  the  whole  abdomen.^  In 
neither  of  these  cases  was  there  jaundice.  I  have,  however, 
met  with  more  than  one  instance  in  which  the  right  kidney  was 
enormously  enlarged  from  cancer,  and  where  jaundice  was  in- 
duced by  secondary  deposits  in  the  glands  in  the  portal  fissure. 

'  Dictionary  of  Medicine,  vol.  ii.  p.  302. 

^  The  details  of  this  case  were  published  by  Dr.  Vanderbyl  in  the  Pathological 
Transactions,  vol.  vii.  p.  268. 

A   A.   2 


356  JAUNDICE  LECT.  X. 

The  diag-nosis  of  jaundice  from  the  pressure  of  an  enlarged 
kidney  on  the  bile-duct  must  rest  on  the  clinical  characters  of 
enlargement  of  the  kidney,  to  which  I  have  already  referred  in 
my  first  lecture  (p.  14). 

6.  A  Retro-jperitoneal  or  Omental  Tumour. 

A  tumour  originating  behind  the  peritoneum  and  growing 
forwards  into  the  abdomen  may  ultimately  involve  and  compress 
the  bile-duct  and  cause  jaundice ;  and  a  tumour — cancerous, 
colloid,  or  tubercular — originating  in  the  omentum  may  lead  to 
a  like  result.^  The  bile-ducts  passing  through  the  morbid 
growth  are  compressed  and  narrowed,  and  rendered  completely 
impervious.  These  tumours  are  usually  cancerous,  and  by  the 
time  that  they  are  large  enough  to  compress  the  bile-duct  their 
existence  is  sufficiently  obvious.  The  chief  difficulty  in  diagno- 
sis will  arise  in  determining  the  place  of  origin  of  the  tumour. 
It  may  be  difficult,  for  instance,  to  distinguish  an  omental 
tumour  in  the  vicinity  of  the  liver  and  compressing  the  bile- 
duct  from  a  tumour  of  the  liver  itself;  and,  indeed,  for  the 
solution  of  the  question  we  must  trust  entirely  to  its  history 
and  mode  of  growth.  Unfortunately,  so  far  as  prognosis  and 
treatment  are  concerned,  the  precise  locality  of  origin  of  the 
tumour  matters  little.  No  known  treatment  can  prevent,  or 
long  defer,  the  fatal  event. 

7.  An  Abdominal  Aneurism. 

In  very  rare  cases  of  aneurism  of  the  abdominal  aorta,  the 
tumour,  when  very  large,  may  compress  the  bile-duct  and  cause 
jaundice.  Dr.  Hutton,  for  instance,  has  recorded  a  case  where 
the  tumour  reached  from  the  crest  of  the  ilium  to  the  lower  end 
of  the  scapula  and  caused  jaundice.  You  will  find  it  referred 
to  in  Dr.  Stokes's  classical  work  on  Diseases  of  the  Heart  and 
Aorta.^  But  in  aneurism  of  certain  of  the  branches  of  the 
abdominal  aorta  jaundice  is  more  common,  and  it  is  particularly 
liable  tobe  produced  by  aneurisms  of  the  hepatic  artery.  Frerichs 
has  collected  four  cases  ^  of  aneurism  of  the  hepatic  artery  from 
different  sources,  from  which  it  would  appear  that  although  the 

'  Sec  a  CiiKe  of  cancer  of  lesser  omentum  in  Pathological  Transactions,  vol.  ix.  p. 
225;  and  another  of  colloid  of  lesser  omentum,  ib.  vol.  xvii.  p.  136,  both  roconlcd 
by  Dr.  l^ristowe. 

2  Th«  Disoa.scs  of  the  Heart  and  Aorti,  18o4,  p.  633. 

3  Frerichs,  op.  cit.  vol.  ii.  p.  378.     Frerichs  makes  five  ca.ses,  but  one  of  the  five, 


LECT.  X.  PROM    OBSTRUCTION    OP    BILE-DTJCT.  35/ 

lesion  is  rare,  it  has  well-defined  characters  during  life.     These 
are  mainly — 

1.  Symptoms  of  imperfect  duodenal  digestion,  pain  in  the 
duodenum  and  its  vicinity  occurring  two  or  three  hours  after 
taking  food. 

2.  Paroxysms  of  acute  neuralgic  pain  in  the  region  of  the 
liver,  simulating  the  colic  of  gall-stones,  and  due,  no  doubt,  to 
the  pressure  of  the  aneurism  on  the  hepatic  plexus  of  nerves. 

3.  Persistent  jaundice  from  compression  of  the  bile-duct. 

4.  Attacks  of  hsematemesis  and  bloody  stools,  and  great 
anaemia  in  consequence. 

5.  A  tumour  in  the  right  hypochondrium,  which  may  dis- 
place the  liver  upwards.  The  nature  of  the  case  would  be 
rendered  still  more  certain  by  detecting  in  this  tumour  pulsa- 
tion and  a  single  or  double  bellows-murmur.  In  a  case,  how- 
ever, recorded  by  Dr.  Stokes,  there  was  no  pulsation. 

In  three  of  the  four  cases  collected  by  Prerichs  the  aneurism 
burst  before  death — twice  into  the  abdominal  cavity,  and  once 
into  the  gall-bladder. 

Similar  symptoms  have  been  noticed  in  cases  of  aneurism 
of  the  superior  mesenteric  artery,  although  in  this  form  of 
aneurism  jaundice  is  less  common,  and  hsemorrhages  perhaps 
more  so.  There  was  no  jaundice  in  the  patient  from  whose  body 
I  removed  this  specimen  some  years  ago — a  man  aged  42,  who 
died  in  this  (Middlesex)  hospital  on  September  27,  1860,  of 
profuse  haemorrhage  from  the  stomach  and  bowels,  in  conse- 
quence of  the  rupbure  of  an  aneurism  of  the  superior  mesenteric 
artery  into  the  duodenum.  Neither  was  jaundice  noted  in  any 
of  three  cases  of  aneurism  of  the  superior  mesenteric  artery, 
recorded  in  the  Pathological  Transactions.'  Two  cases,  how- 
ever, of  superior  mesenteric  aneurism  are  related  by  Dr.  J.  A. 
Wilson  in  the  Medico-Chirurgical  Transactions,^  in  one  of 
which  large  quantities  of  blood  were  vomited,  while  the  other 
'  by  pressure  on  the  hepatic  apparatus  during  life  had  induced 
jaundice.'  A  very  interesting  case  also  is  recorded  by  Dr.  W. 
T.  Gairdner,  where  jaundice  was  produced  by  an  aneurism  of 
the  superior  mesenteric  artery,  which  opened  into  the  duodenum 

quoted  from  Stokes,  as  observed  by  Dr.  Beatty,  was  an  aneurism  of  the  aorca,  not  of 
the  hepatic  artery. 

'  Dr.  J.  W.  Ogle's  case,  vol.  viii.  p.  168 ;  Mr.  Holmes's'  case,  vol.  ix.  p.  172  ;  and 
Dr.  Wilks's  case,  vol.  xi.  p.  44. 

2  Vol.  xxiv.  p.  221. 


358  JAUNDICE  XECT.  X. 

22  months  before  death,  and  caused  repeated  and  very  copious 
hsematemesis  with  symptoms  closely  resembling  those  of  gastric 
ulcer.  From  this  case  Dr.  Gairdner  concluded :  '  that  the 
combination  of  jaundice  with  symptoms  indicating  imperfect 
duodenal  digestion  (cardialgia,  pain  and  vomiting  some  time 
after  taking  food)  should  in  all  cases  lead  to  the  strong  sus- 
picion of  a  tumour  pressing  on  the  ducts  of  the  liver  and 
pancreas  near  their  duodenal  termination ;  that  the  co- 
existence of  these  symptoms  with  fixed  pain  or  oppression  at 
the  epigastrium,  pulsation  in  the  same  region,  and  hsematemesis, 
would  very  probably  indicate  aneurismal  tumour,  even  in  the 
absence  of  more  unequivocal  signs.' ' 

8.  Accumulation  of  Fceces  in  the  Bowels. 

Great  accumulations  of  hardened  faeces  in  the  bowels  may 
also  compress  the  bile-duct,  so  as  to  cause  jaundice  and  lead  to 
serious  errors  in  diagnosis,  hardened  scybala  being  supposed 
to  be  nodules  of  cancer.  Dr.  Bright  has  recorded  several 
instances  of  fsecal  accumulation  in  the  colon,  mistaken  for 
enlargement  of  the  liver  or  malignant  tumours,  and  in  one  of 
them  there  was  jaundice  which  disappeared  after  free  evacua- 
tion of  the  bowels. 2  Frerichs  also  relates  a  case  where  an 
enlargement  of  the  abdomen  from  fsecal  accumulation  was  at 
first  ascribed  to  a  pregnant  uterus,  and  subsequently,  on  the 
supervention  of  deep  jaundice,  to  an  enlarged  liver,  but  where 
purgatives  dispelled  the  patient's  anxiety  about  a  diseased  liver 
and  at  the  same  time  her  hopes  of  a  child.^  Errors  in  diagnosis 
from  this  cause  are  all  the  more  likely  to  arise,  inasmuch  as 
great  faecal  accumulation  may  occur  notwithstanding  that  the 
bowels  have  acted  daily  or  even  been  relaxed.  They  may  be 
avoided,  however,  by  attention  to  the  following  rules : — 

1.  On  careful  manipulation,  the  doughy  consistence  and 
irregular  outline  of  the  faecal  mass  will  often  distinguish  it  from 
all  other  abdominal  tumours. 

2.  In  all  cases  of  doubt,  the  judicious  use  of  laxatives  and 
enemata  will  get  rid  both  of  the  tumour  and  of  the  jaundice. 

9.  A  Pregnant  Uterus. 

Cases  have  been  frequently  observed  where  the  presence  of 
a  pregnant  uterus,  often  in  conjunction  with  constipated  bowels, 

'   Clinical  Medieino,  1862,  p.  504. 

*  Abdominal  Tuiuours.     Syd.  Soc.  Ed.  p.  243.  *  Op.  cit.  vol.  i.  p.  69. 


XECT.  X.  FROM    OBSTRUCTION    OF    BILE-DUCT.  359 

has  caused  jaundice,  the  course  of  which  will  be  recognised  by 
its  appearing  in  the  advanced  stages  of  pregnancy  and  disap- 
pearing after  parturition. 

10.  Ovarian  and  Uterine  Tumours. 

Tumours  of  the  uterus  and  ovary  have  in  rare  instances 
been  known  to  compress  the  bile-duct  and  cause  jaundice.  It 
is  sufficient  here  to  mention  the  fact,  as  the  diagnosis  of  these 
diseases  from  other  cases  of  obstruction  of  the  bile-duct  can 
seldom  be  difficult. 

Prognosis  in  Jaundice  from  Obstruction  of  the  Bile-duct. 

The  prognosis  in  jaundice  from  obstruction  of  the  bile-duct 
will  depend  mainly  on  the  cause  of  the  obstruction.  If  the 
cause  be  a  disease  which  is  of  itself  mortal,  such  as  cancer,  the 
jaundice  will  be  of  secondary  moment  as  regards  prognosis. 
As  to  the  jaundice  itself  the  prognosis  will  vary  according  as 
the  obstruction  is  one  that  admits,  or  does  not  admit,  of  re- 
moval. In  both  cases  it  is  a  matter  for  enquiry,  how  long  a 
person  can  live  with  obstruction  of  the  common  bile-duct.  For 
some  months  but  little  inconvenience  may  be  experienced,  but 
usually  death  from  exhaustion  takes  place  within  eighteen 
months,  the  fatal  result  being  often  preceded  and  hastened  by 
hssmorrhage  from  the  bowels  or  cerebral  symptoms.  It  is  also 
worth  enquiring  how  long  a  gall-stone  may  be  impacted  in  the 
common  bile-duct,  and  yet  ultimately  escape,  so  that  the  jaun- 
dice disappears  and  the  patient  recovers.  It  is  remarkable  how 
few  observations  there  are  on  record,  enabling  one  to  give  a 
satisfactory  reply  to  this  question.  Some  years  ago  I  was  con- 
sulted in  the  case  of  a  gentleman  aged  56,  who  had  deep  jaun- 
dice from  an  impacted  gall-stone  for  twenty  months,  and  at 
the  end  of  that  time  completely  recovered.  Dr.  Ramskill  has 
recently  reported  the  case  of  a  man  who  lived  for  2|-  years 
with  jaundice  from  an  impacted  gall-stone ;  ^  and  Dr.  Budd  has 
recorded  the  case  of  a  man  who  had  jaundice  for  four  years 
from  what  appeared  to  be  closure  of  the  common  bile-duct,  and 
at  the  end  of  that  time  was  tolerably  stout  and  muscular;'^ 

'  Lancet,  March  11,  1876.  The  patient  recovered,  and  for  eighteen  mouths  was 
well  and  free  from  jaundice  (excepting  a  temporary  attack  after  biliary  colic),  but 
died  at  last  of  pysemic  hepatitis. 

2    Dis.  of  Liver,  3rd  ed.  1857,  p.  233. 


360  JAUNDICE  LECT.  X. 

but  Case  CXVIIT.  seems  to  show  that  jaundice  from  gall-stone, 
after  lasting  continuously  for  nearly  six  years,  may  completely 
disappear.  In  connection  with  this  subject  it  is  interesting  to 
observ^e  that  when  the  common  bile-duct  is  ligatured  in  one  of 
the  lower  animals,  the  bile  after  a  time  finds  a  passage  into  the 
intestine  outside  the  ligature.' 

Treatment  of  Jaundice  from  Obstruction  of  the  Bile-duct. 

It  has  been  truly  observed  that  in  no  ailment  have  remedies 
so  worthless  and  absurd  been  extolled  for  their  elficacy  as  in 
jaundice.  The  patient  gets  well,  and  the  remedy  last  tried, 
such  as  taraxacum  or  yelk  of  eggs,  is  said  to  have  cured  him. 
All  scientific  and  really  successful  treatment  must  be  directed 
against  the  cause  of  the  jaundice. 

The  treatment  for  jaundice  arising  from  obstruction  of  the 
bile-duct  may  be  considered  under  two  heads,  viz.  : — 

A.  Those  measures  which  are  calculated  to  remove  the  ob- 
struction ;  and 

B.  The  remedies  which  are  most  likely  to  alleviate  the  effects 
of  the  obstruction. 

A.  The  measures  to  be  adopted  for  the  removal  of  the  ob- 
struction must  depend  on  its  nature.  Some  of  the  causes  of 
obstruction  are  removable,  while  others  are  not.  It  may  be  well 
therefore  to  refer  to  the  several  causes  of  obstruction  in  succes- 
sion, and  first  with  regard  to  — 

a.  Gall-stones. 
Under  this  head  we  have  first  to  consider  what  are  the  best 
means  for  expediting  the  passage  of  the  stone  and  preventing 
its  impaction,  for  the  longer  time  the  calculus  occupies  in  its 
passage,  the  more  likely  is  it  to  produce  ulceration  and  stricture 
of  the  bile-duct,  and  become  permanently  arrested  ;  and 
secondly,  to  enquire  if  there  be  any  remedies  which  have  the 
power  of  obviating  the  formation  of  fresh  concretions,  or  of  dis- 
solving those  which  already  exist  in  the  gall-bladder  or  biliary 
passages. 

I.  Measures  for  expediting  the  passage  of  the  Gall-stone. 

1.  When,  from  the    symptoms  which  I    have  already  de- 
scribed to  you,  there  is  reason  to  believe  that  a  gall-stone  is 

'  Sir  B.  Brodie,  Quarterly  Journ.  of  Science,  London,  1823,  vol.  xiv. ;  and   Dr. 
Wickham  Legg,  Barth.  Hosp.  Rep.  vol.  ix.  1873. 


i.ECT.  X.  FROM    OBSTEUCTION    OF    BILE-DUCT.  361 

passing-  along  the  bile-duct,  it  will  be  well  when  possible  to  put 
the  patient  in  a  warm  bath,  and  in  all  cases  to  apply  heat 
locally  in  the  form  of  warm  fomentations  and  poultices. 

2.  If  there  be  acute  tenderness  on  pressure  over  the  gall- 
bladder, and  the  attack  has  lasted  long,  great  relief  will  often 
be  obtained  from  the  application  of  a  few  leeches  over  the 
region  of  the  gall-bladder. 

3.  Along  with  these  measures  you  must  have  recourse  to  full 
and  repeated  doses  of  opium  or  morphia.  In  consequence  of  the 
vomiting  these  remedies  ought  to  be  given  in  the  form  of  pill. 
A  grain  of  solid  opium  or  quarter  of  a  grain  of  morphia  may  be 
given  every  two  hours  until  the  pain  subsides ;  or,  what  is  still 
better,  from  the  rapidity  of  its  action,  half  a  grain  of  morphia 
may  be  injected  beneath  the  skin  of  the  arm,  and  the  operation 
maybe  repeated  from  time  to  time  according  to  its  effect.  When 
the  patient  is  at  a  distance  fi-om  medical  advice,  morphia  may 
be  administered  in  the  form  of  suppository. 

4.  Belladonna  is  another  remedy  which  often  gives  great 
relief,  and  is  especially  useful  when  opium  is  from  any  cause 
contraindicated.  Half  a  grain  of  the  extract  may  be  given 
every  two  hours ;  or  a  suppository  containing  half  a  grain  of 
morphia  and  one  grain  of  extract  of  belladonna,  or  a  subcu- 
taneous injection  of  one  sixtieth  of  a  grain  of  atropine  with 
quarter  of  a  grain  of  morphia  may  be  used  every  two  hours  until 
the  pain  ceases.  Belladonna  and  chloroform  liniment,  applied 
as  a  fomentation  over  the  liver  under  oil-silk,  also  sometimes 
affords  great  relief. 

5.  Chloroform  and  ether  given  by  the  mouth,  or  better  in 
the  form  of  inhalation,  have  also  been  found  to  be  most  effica- 
cious; and  they  possess  this  advantage,  that  while  they  relieve 
pain,  diminish  spasm,  and  are  rapid  in  their  action,  as  in  the 
case  of  the  uterus  in  parturition  they  do  not  interfere  with 
that  muscular  contraction  which  probably  assists  in  the  onward 
propulsion  of  the  stone. 

6.  Immediate  relief  is  sometimes  afforded  by  large  draughts 
of  hot  water,  containing  from  one  to  two  drachms  of  bicarbo- 
nate of  soda  to  the  pint.  According  to  Dr.  Prout,  who  first  re- 
commended this  plan  of  treatment,  '  the  alkali  counteracts  the 
distressing  symptoms  produced  by  the  acidity  of  the  stomach, 
while  the  hot  water  acts  like  a  fomentation  to  the  seat  of  pain. 
The  first  portions  of  water  are  commonly  rejected  almost  imme- 
diately ;  but  others  may  be  repeatedly  taken,  and  after  some 


"i^^l  JAUNDICE  LECT.  X. 

time  it  will  usually  be  found  that  the  pain  will  become  less,  and 
the  water  be  retained.  Another  advantage  of  this  plan  of 
treatment  is,  that  the  water  abates  the  severity  of  the  retching, 
which  is  usually  most  severe  and  dangerous  where  there  is 
nothing  on  which  the  stomach  can  react.  This  plan  does  not 
supersede  the  use  of  opium,  which  may  be  given  in  any  way 
deemed  most  desirable  ;  and  in  some  instances  a  few  drops  of 
laudanum  may  be  advantageously  conjoined  with  the  alkaline 
solution,  after  it  has  been  once  or  twice  rejected.' ' 

7.  Vomiting  of  the  food  which  is  in  the  stomach  does  not 
require  to  be  checked,  but  when  there  is  frequent  and  severe 
retching  attended  with  pain,  its  continuance  will  lower  the  vital 
powers  and  increase  the  danger  of  rupture  of  the  distended 
gall-bladder  or  bile-ducts,  and  it  must  be  checked  by  efferves- 
cing draughts,  hydrocyanic  acid,  and  ice.  On  the  other  hand, 
when  the  jaundice  is  persistent  and  all  symptoms  of  biliary  colic 
have  long  ceased,  an  emetic  may  dislodge  the  impacted  stone  and 
favour  its  propulsion. 

8.  Purgatives  are  of  little  use  in  expelling  the  stone,  and 
will  exhaust  the  patient ;  but  after  the  paroxysm  of  pain  is  over, 
saline  and  mercurial  purgatives  are  usually  required  to  counter- 
act the  constipating  effect  of  the  opium  and  to  relieve  the 
congestion  of  the  liver. 

9.  Antimony  was  long  ago  recommended  by  Dr.  Bright, 
with  the  object  of  relaxing  spasm,  but  it  must  be  used  with 
caution,  as  it  is  apt  to  increase  the  sickness  and  add  to  the 
exhaustion  which  is  the  patient's  main  danger. 

II.  3l€asures  for  dissolving  or  preventing  the  formation  of 
Gall-stones. 

1.  There  are  certain  remedies  which  are  believed  to  have 
the  power  of  preventing  the  formation  of  fresh  stones,  or  even 
of  dissolving  those  already  existing  in  the  gall-bladder.  A 
combination  of  ether  (three  parts)  and  turpentine  (two  parts), 
proposed  by  Durande,  a  physician  of  Dijon  in  France,  for  a  long 
time  enjoyed  a  reputation  on  the  Continent  for  this  purpose ; 
and  within  the  last  few  years,  another  French  physician,  Bouchut, 
has  claimed  the  same  virtue  for  chloroform  administered  inter- 
nally.2     But  although  both  chloroform  and  ether  will  dissolve 

'  On  tlie  Nfiture  and  Treatment  of  Stomach  and   Urinary  Diseases,  3rd  ed.  1840, 
p.  263. 

-  See  also  Dr.  Barclay,  Brit.  Med.  Jouru.  .Jan.  lo,  1870. 


LECT.  X.  FKOM    OBSTEUCTION    OP    BILE-DUCT.  363 

cholesterin,  which,  is  the  main  constituent  of  gall-stones,  out 
of  the  body,  neither  can  reach  the  gall-bladder  or  bile-ducts 
in  a  sufficiently  concentrated  form  to  accomplish  this  object 
during  life,  and  the  good  effects  which  were  thought  to  follow 
their  use  must  be  ascribed  to  their  antispasmodic  properties, 
and  to  the  relief  which  they  afford  to  flatulence. 

2.  It  is  possible,  however,  that  gall-stones  may  be  dissolved. 
Concretions  are  occasionally  seen  whose  surfaces  exhibit  un- 
mistakable signs  of  erosion.  The  remedies  which  are  believed 
to  possess  this  power  in  the  most  marked  degree  are  saline 
purgatives,  alkalies,  and  diluents.  You  will  do  well  then  to 
give  your  patients  who  have  suffered  from  gall-stones  the  salts 
of  soda  and  potash,  such  as  the  sulphate,  the  tartrate,  the 
phosphate,  and  the  bicarbonate,  the  sulphate  of  magnesia  or  the 
chloride  of  ammonium,  largely  diluted,  or,  what  is  still  better, 
when  practicable,  send  them  to  drink  the  saline  and  alkaline 
mineral  waters  of  Carlsbad,  Marienbad,  Homburg,  Yichy,  Con- 
trexeville,  &c.  Although  it  must  be  confessed  that  the  evidence 
of  the  efficacy  of  mineral  waters  and  alkalies  in  dissolving  gall- 
stones is  inconclusive  and  must  remain  so,  there  can  be  little 
doubt  that  they  improve  the  general  health,  lessen  the  tendency 
to  acid  dyspepsia  and  gout,  reduce  congestion  of  the  liver, 
and  produce  such  changes  in  the  bile  as  lessen  the  chances  of 
the  formation  of  fresh  concretions.  In  dogs,  for  instance,  with 
biliary  fistulse,  the  mere  drinking  of  large  quantities  of  water 
will  increase  the  amount  of  water  in  the  bile,  and  there  is 
evidence  that  the  quantity  of  soda  in  the  bile  may  also  be  in- 
creased by  taking  it  into  the  stomach.  From  the  frequency 
also  with  which  attacks  of  biliary  colic  occur  during  or  imme- 
diately after  a  course  of  saline  or  alkaline  mineral  waters,  it 
would  seem  that  in  some  way  they  determine  a  crisis  in  the 
case  and  favour  the  expulsion  of  the  stones. 

3.  In  all  cases  it  will  be  necessary  to  attend  to  the  patient's 
digestion  and  general  health.  Small  doses  of  blue  pill  are 
sometimes  very  useful.  According  to  Dr.  G.  Budd,  no  medicine 
in  some  cases  does  such  signal  good.  '  It  seems  to  increase 
the  quantity  of  bile  and  at  the  same  time  to  render  it  more 
healthy,  and  certainly  often  improves  in  a  striking  manner  the 
general  health.'  ^  This  statement  is  in  complete  harmony  with 
my  own  experience. 

4.  Lastly,  it  will  be  necessary  to  counteract  those  habits  on 

'  Op.  cit.  p.  387. 


364  JAUNDICE  LECT.  X. 

the  pait  of  the  patient  which  exi^erience  has  shown  to  conduce 
to  the  formation  of  gall-stones.  He  must  rise  early  and  take 
plenty  of  exercise  in  the  open  air,  sleep  iu  an  airy  bedx'oom, 
live  sparely,  drink  little  or  no  wine,  and  avoid  all  rich,  fatty,  and 
saccharine  food  and  malt  liquors. 

h.  Hydatids,  Distomata,  and  other  foreign  bodies  in  the  Bile- 
ducts. 

These  causes  of  obstruction  of  the  bile-duct  must  be  treated 
on  the  same  principles  as  gall-stones,  with  anodynes  and  anti- 
spasmodics. The  bursting  of  a  hydatid  tumour  into  the  bile- 
duct  is  usually  preceded  by  more  or  less  peritonitis  and  followed 
by  inflammation  of  the  hydatid,  which  will  call  for  absolute 
rest,  leeches,  warm  fomentations  and  opiates.  (See  Cases  XXXII. 
to  XXXIV.  p.  112.) 

c.  Inflavnnfiation  of  the  Bile-ducts. 

The  treatment  for  obstruction  of  the  bile-duct  by  inflamma- 
tory obstruction  of  the  lining  membrane  with  exudation  in  the 
interior  has  been  considered  in  a  former  lecture  (p.  154). 

d.  Organic  Stricture  and  Tumours  of  the  Bile-duct. 
For  the  various  forms  of  organic  obstruction  of  the  bile-duct 
arising  from  stricture  or  obliteration  of  the  duct  or  from  tumours 
growing  in  its  interior,  no  treatment  is  likely  to  be  of  any 
avail.  The  obstruction  is  irremovable,  and  the  jaundice  is  per- 
manent. In  cases,  however,  where  there  has  been  a  history 
of  syphilitic  peri-hepatitis,  mercury  and  iodide  of  potassium 
deserve  a  trial. 

e.  Pressure  on  the  Bile-duct  from  without. 

When  the  obstruction  is  due  to  pressure  on  the  duct  from 
without,  the  treatment  must  vary  according  to  the  compressing 
cause.  Some  of  these  causes  are  removable ;  others  are  not. 
When  the  pressure  is  due  to  an  abscess  or  hydatid  of  the  liver, 
or  to  an  ovarian  cyst,  it  will  be  removed  on  evacuation  of  the 
fluid  contents  of  the  tumour  ;  but  the  pressure  of  cancerous 
nodules  projecting  from  the  liver,  enlarged  cancerous  glands  in 
the  portal  fissure,  tumours  of  the  stomach,  pancreas,  kidney, 
omentum,  and  uterus,  and  of  abdominal  aneurisms,  cannot  be 
influenced  by  treatment.  When  the  symptoms  point  to  waxy 
or  tubercular  glands  in  the  fissure  of  the  liver  as  the  cause  of 


LECT.  X.  FROM    OBSTRUCTION    OF    BILE-DUCT.  365 

pressure,  improvement  may  sometimes  be  observed  to  follow 
the  iise  of  iodide  of  potassium,  iron,  nitro-muriatic  acid,  and 
cod-liver  oil,  &c.  (see  Lect.  II).  Fsecal  accumulations  in  tlie 
colon  are  to  be  got  rid  of  by  castor  oil,  the  administration  of 
frequent  small  doses  of  extract  of  belladonna,  and  copious  olea- 
ginous or  warm- water  enemata.  Lastly,  when  jaundice  shows 
itself  during  pregnancy  care  must  be  taken  to  ascertain  whether 
the  pressure  of  the  gravid  uterus  be  not  aggravated  by  accu- 
mulation of  fseces  in  the  bowels. 

B.  In  the  next  place  we  have  to  consider  what  are  the  most 
suitable  remedies  for  relieving  the  effects  of  irremovable  or 
persisting  obstruction  of  the  bile-duct. 

1.  One  of  the  first  effects  of  complete  obstruction  of  the 
bile-duct,  if  it  be  not  speedily  removed,  is  the  accumulation  of 
bile  in  the  bile-ducts  and  gall-bladder,  which  become  greatly 
distended  and  sometimes  inflamed  in  consequence  (see  antea, 
p.  160),  and  under  these  circumstances  advantage  will  often 
be  derived  from  leeches  to  the  right  hypochondrium  or  round 
the  anus,  warm  poultices,  laxatives,  diuretics  and  diaphoretics, 
and  from  taking  as  little  fluid  as  possible  in  the  way  of  drink. 

2.  The  diet  in  all  cases  requires  careful  regulation.  It 
ought  to  be  easy  of -digestion  and  mainly  nitrogenous.  Olea- 
ginous and  saccharine  matters  and  malt  liquors  ought  to  be  for 
the  most  part  excluded. 

3.  The  bowels  will  require  attention.  In  most  cases  they 
are  constipated  and  laxatives  will  be  necessary,  and  of  these 
the  best  is  a  combination  of  the  compound  colocynth  or 
rhubarb  pill  (gr.  vi)  with  blue  pill  (gr.  ij)  and  extract  of  hen- 
bane (gr.  ij).  No  good  can  be  expected  in  such  cases  from 
remedies  which  stimulate  the  action  of  the  liver,  or  from  a 
course  of  mercury  even  supposing  that  mercury  had  the  power 
to  do  this ;  but  there  can  be  no  objection  to  the  use  of  both 
mercury  and  podophyllin,  as  an  occasional  purgative.  Prac- 
tically their  use  in  moderation  is  not  attended  Avith  those  in- 
jurious consequences  which  have  been  theoretically  ascribed  to 
them.  Although  under  ordinary  circumstances  they  produce 
bilious  stools,  there  is  no  evidence,  as  I  have  already  pointed 
out  to  you,  that  mercury  increases  the  amount  of  bile  secreted 
by  the  liver  (p.  330). 

4.  Flatulence  and  other  dyspeptic  symptoms  will  in  many 
cases  call  for  treatment.     The  flatulence  will  often  be  relieved 


366  JAUNDICE  i.ECT.  X. 

by  the  ethers  and  essential  oils,  the  gura-resins  of  assafoetida 
and  galbanum,  and  by  vegetable  charcoal ;  but  in  most  cases 
the  best  remedies  are  those  which  have  antiseptic  properties. 
Bile  is  an  antiseptic,  and  its  withdrawal  from  the  bowels  entails 
decomposition  of  their  contents  with  generation  of  gas,  but  this 
decomposition  will  be  prevented  by  the  use  of  such  remedies 
as  creasote,  turpentine,  and  carbolic  acid  (see  p.  215).  Fla- 
tulence and  other  dyspeptic  symptoms  arising  from  the  want  of 
bile  in  the  bowels  are  also  often  greatly  relieved  by  the  use  of 
purified  bile  from  the  ox  or  pig,  which  may  be  given  in  doses 
of  from  three  to  six  grains  about  two  hours  after  meals.  As  it 
is  not  desirable  that  the  bile  should  come  in  contact  with  the 
stomach,  it  is  well  to  give  it  enclosed  in  capsules,  or  in  pills 
coated  Avith  a  solution  of  tolu  in  ether.  The  cholate  of  soda, 
of  which  ten  grains  may  be  taken  in  peppermint  water,  has 
also  been  found  useful  for  the  same  purpose.  The  alkalies  and 
mineral  acids  (p.  137),  but  more  commonly  the  former,  in 
conjunction  with  calumba,  or  with  taraxacum,  chiretta,  gentian, 
or  quinine,  are  also  often  of  use  for  improving  the  appetite  and 
digestion. 

5.  In  all  cases  of  jaundice  from  obstruction  of  the  ducts 
it  is  important  to  attend  to  the  functions  of  the  kidneys  and 
skin.  The  kidneys  are  the  principal  channels  by  which  the 
accumulated  bile  is  got  rid  of  from  the  system,  and  any  disease 
of  these  organs  (as  in  Case  LXV.  p.  159  and  Case  CV.  p.  298) 
will  add  greatly  to  the  patient's  danger.  Persons  suffering 
from  jaundice  due  to  obstruction  of  the  bile-duct  must  avoid 
sudden  chills,  and  will  be  benefited  by  occasional  warm  baths 
and  by  the  use  of  the  chloride  of  ammonium,  diaphoretics,  and 
diuretics. 

6.  The  itchiness  Mdiich  is  often  a  source  of  much  distress 
will  sometimes  be  alleviated  by  warm  baths,  the  use  of  a  flesh- 
brush,  and  the  internal  administration  of  bicarbonate  of  potash 
(see  p.  318).  A  medical  man,  who  had  suffered  greatly  from 
itchiness  and  jaundice  due  to  gall-stones,  informed  me  that 
among  the  numerous  remedies  which  he  had  tried,  he  had 
experienced  the  greatest  relief  from  acetic  acid  baths  {h  pint 
of  acid  to  3  gallons  of  water),  or  from  a  lotion  of  chloroform 
(1  part)  and  glycerin  (5  parts).  Olive  oil,  calomel  ointment,  or 
lotions  containing  the  perchloride  or  cyanide  of  mercury  (gr.  iv  to 
.5j)  or  the  carbonate  of  potash  or  cyanide  of  potassium  (5J  to  Oj), 
are  also  sometimes  useful.     But  too  often  all  treatment  fails  to 


LECT.  X.  PROM    OBSTRUCTION    OF    BILE-DUCT.  36/ 

give  relief,  and  recourse  must   be   liad   to   opiates   or   otlier 
anodynes  to  procure  sleep. 

7.  When  there  is  great  debility,  or  when  the  patient 
suffers  from  boils  or  carbuncles,  improvement  vfiil  some- 
times follow  the  use  of  the  mineral  acids  with  nux  vomica  or 
bark,  and  it  will  be  necessary  to  allow  small  quantities  of 
alcoholic  stimulants.  Of  these  the  best  are  hock,  dry  sherry, 
sound  claret,  and  diluted  brandy  or  gin. 

8.  When  cerebral  symptoms  supervene,  the  treatment  which 
has  been  found  most  efficacious  consists  in  sinapisms  to  the 
nape  or  scalp,  and  purgatives.  It  will  be  well  also  to  act  on 
the  skin  by  means  of  diaphoretics,  the  warm  bath,  or,  what  is 
better,  by  the  hot-air  bath,  and  especially  if  there  be  no  albu- 
men in  the  urine  to  give  diuretics. 

9.  Occasionally,  the  treatment  may  have  to  be  modified  in 
accordance  with  symptoms  arising  from  the  disease  to  which 
the  obstruction  of  the  bile-duct  is  due,  as,  for  instance,  in  cases 
of  cancer  of  the  stomach,  duodenum,  or  pancreas,  or  of  abdo- 
minal aneurism. 

10.  Lastly,  it  is  well  to  remember  that  in  those  cases  where 
you  succeed  in  removing  the  obstruction,  the  jaundice  of  the 
skin  and  conjunctivee  may  persist  for  a  considerable  time  after- 
wards, and  that  then  its  departure  will  be  expedited  by  warm 
baths,  diaphoretics,  purgatives,  and  diuretics,  and  also  by 
benzoic  acid,  which  may  be  given  in  doses  of  four  grains  made 
up  into  two  pills  with  a  little  glycerin,  three  times  a  day. 

I  shall  now  proceed  to  recall  to  your  notice  the  particulars 
of  a  few  cases  of  jaundice  from  obstruction  of  the  bile-duct, 
which,  for  the  most  part,  have  been  under  your  observation  in 
the  wards. 

The  first  case  was  a  typical  illustration  of  jaundice  from 
gall-stones.  The  case  was  also  remarkable  for  the  large  size  ol 
the  stone  which  passed  through  the  bile-ducts  into  the  bowel. 

Case  CXVI. — Biliary  Golic — Escape  of  a  very  large  Gall-stone  hy  tJie 
Commoih  Duct. 

Elizabeth  G ,  31,  adm.  into  St.  Thomas's  Hospital  April  3,  1872. 

Five  years  before  had  been  suddenly  seized  with  violent  paroxysmal 
pain  in  the  right  hypochondrium,  stretching  round  to  back,  accom- 
panied by  retching,  and  followed  by  deep  janndice,  itchiness  of  skin, 
and  white  stools.     The  pain  and  retching  subsided  after  five  or  six 


268  JAUNDICE  LBCT.  X. 

hours,  but  tlie  jaundice  persisted  for  three  months.  At  end  of  attack 
biliai-y  concretions  were  found  in  stools.  After  eighteen  months  she  had 
a  similar  but  less  severe  attack,  the  jaundice  lasting  only  one  week. 
Five  weeks  before  admission  she  had  a  third  seizure,  and  ever  since 
she  had  had  daily  recurring  attacks  of  pain  in  right  side,  quite  as  severe 
as  upon  first  occasion,  attended  by  retching  and  sometimes  lasting 
seven  hours.  At  beginning  of  attack  skin  had  been  slightly  yellow 
for  a  day  or  two,  but  after  this  there  had  been  no  jaundice. 

On  admission,  conjunctivae  white,  no  jaundice  nor  itchiness  of 
skin,  and  no  bile-pigment  in  urine.  No  enlargement  of  liver  nor  per- 
ceptible bulging  of  gall-bladder,  but  marked  tenderness  corresponding 
to  its  fundus.     Bowels  costive  ;  motions  contain  bile. 

Patient  was  ordered  an  aperient  draught  of  sulphate  and  carbonate 
of  soda  every  morning,  and  for  some  days  felt  better.  On  April  7  and 
9  had  paroxysms  of  pain,  but  not  very  severe.  On  April  16  a 
paroxysm  set  in  much  more  severe  than  any  before.  For  more  than 
four  days  the  pain  was  incessant,  and  was  only  relieved  by  repeated 
injections  of  morphia  under  the  skin.  Patient,  who  had  borne  several 
children,  declared  that  pain  of  labour  was  nothing  to  this  pain.  The 
vomiting  also  was  urgent ;  stools  contained  no  bile,  and  on  second  day 
of  pain  patient  became  deeply  jaundiced.  The  last  paroxysm  of  pain 
occurred  on  night  of  20th,  and  on  night  of  21st  patient  passed  two 
facetted  gall-stones,  about  size  of  small  cherries,  in  a  motion  containing 
plenty  of  bile,  and  a  day  or  two  afterwards  a  third  gall-stone  was 
found  in  stools,  globular  and  fully  two  inches  in  circumference.  For 
some  days  patient  had  much  aching  and  tenderness  in  region  of  liver, 
but  she  had  no  return  of  severe  pain,  jaundice  speedily  subsided,  and 
on  May  4  she  was  able  to  leave  hospital. 

Case  CXVII.  was  very  instructive  as  showing-  how  long 
biliary  colic  may  exist  without  any  jaundice,  the  explanation 
in  this  case  being  the  detention  of  the  stone  from  its  great  size 
in  the  cystic  duct.  It  was  also  a  rare  example  of  death  from 
sheer  exhaustion  in  uncomplicated  gall-stones.  The  post- 
mortem examination  showed  that  if  the  patient  could  have 
survived  a  few  days  longer,  the  stone  would  have  passed  into 
the  bowel  and  she  would  have  recovered. 

Case  CXVII. — Fatal  Jaundice  from  Obstruction  of  Bile-duct  hy  a  large 

Gall-stone. 

In  Oct.  1809,  a  lady  about  45  years  of  age  consulted  me  at  my  house, 
and  gave  following  history.  For  about  thirteen  years  she  had  been 
liable,  at  long  intervals,  to  severe  attacks  of  biliary  colic — pain  in  region 
of  liver,  coining  on  in  violent  paroxysms,  accompanied  by  vomiting 
and  followed  by  jaundice,  which  lasted  for  a  few  days.     During  these 


LECT.  X,  FROM    OBSTRUCTION  OF    BILE-DUCT.  369 

attacks  her  medical  attendant  had  often  noticed  a  painful  swelling, 
corresponding  to  fundus  of  gall-bladder. 

In  autumn  of  1868  she  had  an  unusually  severe  and  protracted 
attack.  About  Christmas  1868  the  attacks  of  pain  became  more 
frequent ;  they  came  on  almost  every  day  without  exception,  usually 
about  four  o'clock  in  afternoon,  and  lasted  for  twelve  hours.  The 
pain  was  accompanied  by  vomiting,  but  all  this  time  there  was  no 
jaundice.  In  April  1869  paroxysms  of  pain  and  vomiting  became 
even  more  frequent  and  much  more  severe,  and  patient  was  reduced 
to  an  alarming  state  of  prostration,  from  which  for  many  days  she  was 
not  expected  to  rally.  At  this  time  liver  was  found  to  be  considerably 
enlarged  and  deep  jaundice  set  in,  which,  though  varying  in  intensity, 
never  disappeared,  motions  from  that  date  being  devoid  of  bile- 
pigment.  For  six  weeks  during  April  and  May  patient  was  confined  to 
bed,  and  although  for  some  months  before  I  saw  her  she  had  been  able 
to  go  about,  she  continued  to  lose  flesh  and  suffered  much  from  itchi- 
ness of  skin,  flatulence,  and  almost  constant  diarrhoea.  She  was  also 
still  liable  to  attacks  of  pain  and  vomiting,  though  less  severe  and 
less  regular  in  their  recurrence. 

I  found  her,  at  time  of  her  visit  to  me,  very  thin  and  weak  and 
deeply  jaundiced.  Liver  was  greatly  enlarged,  but  not  tender  ;  some 
tenderness,  however,  over  a  rather  firm  tumour,  about  size  of  an  orano-e, 
corresponding  to  gall-bladder.  N"o  ascites  and  no  enlargement  of  spleen. 
The  lady  had  already  consulted  several  medical  men  of  eminence, 
and  more  than  one  had  expressed  opinion  that,  whether  there  wore 
galhstones  or  not,  there  was  a  cancerous  tumour  in  fissnre  of  liver. 
This  view  appeared  to  me  to  be  negatived  by  absence  of  ascites  or  of 
any  symptom  of  portal  obstruction,  while  whole  histoiy  of  case  seemed 
to  point  to  a  large  gall-stone,  which  from  Christmas  1868  to  April  1869 
had  made  vain  efforts  to  pass  through  cystic  duct,  and  thus  accounted 
for  attacks  of  biliary  colic  without  jaundice ;  but  which,  during  severe 
attack  in  April,  passed  into  common  duct  and  produced  enlargement 
of  liver  and  permanent  jaundice,  with  mal-assimilation  and  emaciation. 
If  this  were  case,  it  seemed  possible — though,  considerinp-  duration  of 
jaundice,  not  very  probable — that  cause  of  obstruction  might  be  dis- 
charged into  bowel  and  patient  get  well.  I  prescribed  alkalies  and 
creasote  pills  to  relieve  flatulence,  and  gave  instructions  that,  in  event 
of  severe  pain  coming  on,  recourse  should  be  had  to  warm  baths 
opium,  and  chloroform. 

On  afternoon  of  same  day,  probably  owing  to  fatigue  and  shakino- 
consequent  on  journey  from  and  back  to  country,  pain  and  vomitino- 
returned  with  great  severity,  and  continued  to  recur  at  short  intervals 
until  death  from  exhaustion  three  weeks  afterwards.  During  last 
week  of  life  hajmorrhages  occurred  from  different  mucous  membranes, 
and  on  one  occasion,  a  few  days  before  death,  during  a  violent  fit  of 
retching,  patient  felt  a  sudden  sharp  pain  in  region  of  gall-bladder  as 

B  B 


3/0  JAUNDICE,  LECT.  X. 

if  sometlimg  had  burst,  and  soon  after  she  vomited  some  blood  mixed 
with  mucus. 

A  post-mortem  examination  was  made  by  Mr.  Taylor  of  Gruildford, 
who  kindly  furnished  me  with  account  of  appearances  found,  and  with 
opportunity  of  exhibiting  to  the  Pathological  Society  the  obstructed 
bile-duct.  There  Avas  nowhere  any  cancerous  deposit.  Liver  was 
uniformly  enlarged  and  gorged  with  bile.  But  most  remarkable  ap- 
pearance was  enormous  dilatation  of  cystic  and  common  bile-ducts, 
which  admitted  tip  of  index  finger.  Duodenal  end  of  common  duct 
was  blocked  up  by  a  cylindrical  gall-stone,  measuring  about  an  inch 
in  length  and  half  an  inch  in  thickness.  This  projected  into  bowel, 
where  a  portion  of  its  surface  was  bare  and  exposed  from  ulceration  or 
rupture  of  superimposed  mucous  membrane.  Orifice  of  duct  was  not 
enlarged,  and  could  be  seen  like  a  little  dimple  in  centre  of  projection 
caused  by  gall-stone.  It  seemed  probable  that  the  mucous  membrane 
stretched  over  gall-stone  had  given  way,  during  the  attack  of  sudden 
sharp  pain  in  region  of  gall-bladder  followed  by  vomiting  of  blood 
and  mucus,  shortly  before  death.  Seven  smaller  polyhedral  concre- 
tions in  gall-bladder  and  dilated  cystic  duct ;  two  others  in  hepatic 
duct,  and  two  in  dilated  ducts  in  interior  of  liver.  All  had  several 
facet.«,  and  had  probably  been  formed  in  gall-bladder.  Blood  dark 
and  fluid ;  exti'avasations  in  difierent  parts  of  body. 

Case  CXVIII.  is  an  example  of  recovery  after  very  persis- 
tent jaundice  from  gall-stones.  The  case  was  also  remarkable 
for  being  complicated  with  extensive  xanthelasma. 

Case   CXVIII. — TPersistent  Jaundice  from  Gall-stones — Recovery   ajter 
nearly  six  years — Xantlielasma. 

Mrs.    S ,   about  40,   from  Sydney,  consulted  me  on  April  4, 

1871.  Two  years  before,  when  seven  months  pregnant,  began  to 
suffer  from  severe  attacks  of  pain  commencing  suddenly  at  epigastrium, 
and  shooting  to  back  and  right  shoulder.  Pain  would  last  several 
hours  and  then  cease  suddenly,  and  might  return  two  or  tlu"ee  times  in 
a  week ;  it  was  sometimes  attended  by  vomiting,  but  thei'e  was  no 
jaundice.  Two  months  after  confinement  had  an  unusually  severe 
attack  of  pain,  followed  by  intense  jaundice  and  white  stools  which 
lasted  three  weeks  ;  and  for  nearly  a  year  these  attacks  were  so  frequent 
that  jaundice  of  one  attack  had  scarcely  di.sappeared  before  another  came 
on.  During  the  twelve  months  before  I  saw  her,  she  had  had  only  one 
attack  of  pain,  but  there  had  been  persistent  jaundice,  and  she  had  had 
frequent  rigors,  which  were  always  followed  by  an  increase  of  jaundice, 
darker  urine,  and  wliitcr  stools.  She  had  lost  flesh  and  suffered  much 
from  flatulence  and  tightness  and  oppression  after  food,  and  from 
attacks  of  diuriluL'u  with    li^ht  fetid  stools  ;  and    when  I  saw  her  she 


LECT.  X.  FROM    OBSTRUCTION    OF    BILE-DUCT.  371 

was  rather  deeply  jaundiced,  with  large  patches  of  xanthelasma  on 
eyelids  and  neck  ;  urine  was  as  dark  as  porter,  but  motions  contained 
no  bile ;  liver  protruded  about  two  inches  beyond  ribs,  its  lower 
margin  being  hard  and  sharp,  and  projecting  from  this  was  a  rounded 
swelling  about  size  of  a  small  pear,  in  situation  of  gall-bladder. 

The  diarrhoea  was  always  checked  by  creasote  or  ox-gall,  and 
under  these  and  other  remedies  patient  improved,  gained  flesh  and 
strength,  and  lost  dyspeptic  symptoms.  On  July  26  jaundice  was 
very  slight  and  urine  contained  very  little  bile-pigment,  but  there  was 
never  any  decided  sign  of  bile  in  stools.  After  this,  patient  travelled 
about  and  was  able  to  bear  considerable  fatigue ;  the  jaundice  and 
amount  of  bile  in  urine  varied  from  time  to  time,  but  there  was  never 
any  clear  evidence  of  bile  in  stools.  On  Dec.  30,  after  dinner,  she 
suddenly  felt  sick  and  faint,  and  although  she  had  no  pain  she  was 
for  some  days  after  more  yellow.  On  Feb.  2,  1872,  after  a  short  walk, 
she  was  suddenly  seized  with  most  acute  pain  in  region  of  o-all- 
bladder,  shivering,  nausea,  profuse  perspirations,  and  great  restless- 
ness. These  symptoms  were  only  relieved  by  large  opiates,  and  next 
morning  jaundice  had  increased,  and  in  evening  of  Feb.  3  there  was  a 
recurrence  of  the  pain  and  other  symptoms.  For  a  week  after  this 
patient  was  extremely  prostrate  and  feverish,  had  frequent  retchino- 
and  deep  jaundice  and  acute  pain  at  tip  of  right  shoulder,  with  much 
fulness  and  tenderness  in  region  of  gall-bladder.  In  night  of  Feb.  9 
she  was  suffering  so  much  that  she  had  a  subcutaneous  injection  of 
morphia,  which  at  once  relieved  her ;  and  next  morning  she  vomited  a 
quantity  of  green  bile  for  first  time  for  nearly  two  years.  After  this 
she  improved ;  on  Feb.  14  she  was  up  and  about ;  jaundice  almost 
though  never  quite,  disappeared,  and  motions  contained  bile.  No 
stone  was  found  in  motions,  but  they  were  not  examined  with  suffi- 
cient care.  On  May  26  had  an  attack  similar  to  that  on  Feb.  2,  but 
less  severe,  yet  followed  by  fever,  tenderness  about  gall-bladder,  and 
increased  jaundice.  A  few  days  after  this  patient  returned  to  Sydney  ; 
but  I  continued  to  hear  of  her  from  time  to  time.  Before  she  left  I 
ascertained  that  liver  was  about  an  inch  smaller  than  it  had  been  a 
year  before.     She  was  still  rather  deeply  jaundiced. 

Until  end  of  1874  she  continued  much  in  same  state  as  when  at 
home,  except  that  she  was  much  weaker.  She  had  no  severe  pain,  but 
she  had  frequent  fainting  attacks  followed  by  an  increase  of  jaundice, 
from  which,  however,  she  was  never  quite  free.  But  in  1875  jaundice 
quite  disappeared,  and  general  health  and  strength  improved  ;  and  in 
1876  this  improvement  continued. 

In  a  former  lecture  I  have  called  your  attention  to  the 
difficulty  there  often  is  in  distinguishing  between  jaundice  from 
gall-stones  and  jaundice  from  ca.ncer  (p.  213).  In  both  there 
may  be  intense  jaundice,  no  bile  in  the  stools,  great  emaciation 


372  JAUNDICE,  LECT.  X. 

and  weakness,  and  parox3'sms  of  severe  pain.  The  difficulty 
is  increased  by  the  circumstance  that  cancer  of  the  liver  is  a 
common  sequel  of  gall-stones.  At  Gny's  Hospital,  indeed,  it 
has  been  found  that  when  death  occurs  in  persons  with  gall- 
stones, it  is  most  frequently  brought  about  by  the  development 
of  cancer  about  the  gall-bladder  or  bile-ducts.^  Case  CXIX. 
was  further  interesting  from  the  circumstance  that  although 
the  obstruction  of  the  common  bile-duct  was  not  removed,  bile 
appeared  in  the  stools  before  death  owing  to  the  establishment 
of  a  fistulous  past  age  between  a  dilated  bile-duct  and  the 
stomach. 

Case  CXIX. — Gall-stone    impacted   in    common    Bile-duct. — Fistulous 
opening  of  dilated  Bile-ducts  into  Stomach — Cancer  of  Liver. 

Elizabeth  W ,  aged  64,  adm.  into  St.  Thomas's  Hosp.  Jan.  21, 

1876.  No  history  of  cancer  in  family  could  be  made  out.  A.  sister 
had  died  at  54  of  asthma.  Patient  had  been  of  temperate  habits,  and 
bad  enjoyed  good  hea  th  until  present  illness.  For  four  years  she  had 
suffered  from  attacks  of  severe  pain  in  region  of  gall-bladder,  recarring 
at  intervals  of  four,  five,  or  six  months.  The  pain  would  come  on  in 
paroxysms  for  three  c  r  four  days  and  was  severe,  so  that  she  was  laid 
up  for  ten  or  fourteen  days,  but  it  was  never  attended  by  vomiting  nor 
followed  by  jaundice.  Towards  end  of  July  1875  she  had  an  unusually 
severe  and  protracted  attack,  and  after  six  weeks  from  commencement 
of  attack,  although  pain  had  subsided,  jaundice  appeared  for  first  time 
and  persisted,  and  from  this  date  she  lost  appetite,  flesh,  and  strength. 
She  still  suffered  from  indefinite  pains,  but  after  appearance  of  jaundice 
she  never  had  the  severe  paroxysjns  such  as  she  had  had  before.  Five 
weeks  before  admission,  she  was  attacked  with  diarrhoea  (light  coloured 
stools),  which  ceased  after  three  weeks.  For  four  weeks  she  had  had 
a  frequent  harassing  cough. 

On  admission,  emaciated  and  deeply  jaundiced.  Tongue  slightly 
coated,  not  too  red  ;  appetite  improved  ;  bowels  regular  ;  motions  re- 
ported as  light-coloured.  In  right  nipple  line  liver  did  not  seem  to 
extend  beyond  mar<;in  of  ribs,  hut  between  this  and  left  nipple  line 
could  be  distinctly  fe't  a  solid  mass,  apparently  continuous  with  liver, 
and  extending  to  2^  in.  below  umbilicus,  smooth,  firm,  and  not  tender, 
although  pressure  upon  it  caused  pain  in  back.  Lower  part  of  chest 
contracted  from  lacing.  No  ascites.  Urine  1015,  loaded  with  bile- 
j)ignicnt,  but  no  all  umen.  Pulse  84,  weak  ;  heart-sounds  healthy. 
Frequent  cough  with  muco-puruleiit  expectoration  ;  a  few  sibilant  rales 
over  front  of  both  lungs  ;  posteriorly  over   lower   fourth  of  left  lung, 

'  F;  ggc,  Guy's  IIosp.  Kop.  1876,  vol.  xx. 


LBCT.  X.  FROM    OBSTRUCTION    OF    BILE-DTJCT.  373 

marked  dulness,  distinct  tubular  breathing,  diminished  vocal  resonance, 
and  coai'se  moist  rales.     Temp.  96'8°  to  99'2°.     Frequent  headache. 

Patient  was  treated  with  nux  vomica  and  mineral  acids,  and  a  nu- 
tritious diet  with  a  raoderate  amount  of  stimulants.  At  first  she  im- 
proved a  little  ;  but  on  Jan.  31,  weaker  ;  much  pain  in  back ;  appetite 
less;  bowels  costive  ;  distinct  evidence  of  bile  in  stools  ;  jaundice  un- 
changed ;  sleeps  badly.  Under  draughts  of  morphia  at  night  slept 
better  and  again  improved  a  little,  and  on  Feb.  26  dulness  was  noted 
as  having  quite  disappeared  from  base  of  left  lung,  where  there  was 
now  vesicular  breathing.  But  after  this  became  rapidly  weaker,  and 
pain  in  back  was  more  severe.  On  March  9  she  vomited  a  quantity 
of  dark  liquid,  passed  into  a  state  of  collapse,  and  died  same  even- 
ing. All  time  she  was  under  observation  pain  never  had  characters  of 
biliary  colic. 

Autopsy. — Body  very  emaciated.  Peritoneum  contained  a  small 
quantity  of  fluid  ;  abdominal  organs  adherent  by  a  thin  layer  of  recent 
lymph..  Liver  much,  displaced,  left  lobe  occupying  greater  part  of 
right  half  of  abdomen,  reaching  6  in.  below  ribs  in  right  nipple  line  ; 
right  lobe  displaced  upwards  and  backwards,  pushing  up  right  half  of 
diaphragm,  and  not  visible  from  front  of  abdomen.  Left  lobe  thin  and 
contained  several  small  nodules  of  cancerous  growth.  Gall-bladder 
moderately  distended  with  colourless,  nearly  clear  mucus.  Common 
bile-duct  contained  similar  mucus,  and  uniformly  distended  to  about 
five  lines  in  diameter  ;  about  1  in.  from  its  termination  in  duodenum 
a  calculus,  size  of  a  small  marble,  was  found  impacted,  and  above  this 
were  several  smaller  dark  concretions.  A  probe  passed  upwards  into 
hepatic  duct  entered  a  large  mass  of  cancerous  growth,  occupying 
centre  of  liver  and  extending  forwards  to  neighbourhood  of  gall- 
bladder, hard  and  fibrous  externally,  but  in  centre  much  degenerated 
and  containing  calcareous  masses.  Bile-ducts  throughout  liver,  but 
especially  those  in  left  lobe,  greatly  dilated  and  filled  with  thick  bile, 
some  of  dilated  ducts  projecting  from  surface  of  liver.  Stomach  con- 
tained a  quantity  of  greenish-yellow  mucus  giving  reaction  of  bile- 
pigment.  Anterior  wall  of  stomach  adherent  to  under  surface  of  left 
lobe  of  liver  and  at  adherent  portion  were  three  or  four  small  rounded 
orifices,  from  one  to  two  lines  in  diameter,  by  which  stomach  communi- 
cated with  dilated  bile-ducts  in  superficial  portions  of  liver.  On 
squeezing  liver,  bile  flowed  through  them  into  stomach.  This  was 
source  of  bile  found  in  bowels  and  in  stools  during  life.  Spleen  some- 
what enlarged.  Signs  of  recent  inflammation  with  a  pint  of  turbid 
fluid  in  right  pleura.  Numerous  small  nodules  of  new  growth  on 
pleural  surface  of  right  half  of  diaphragm  and  in  substance  of  right 
lung.     A  small  quantity  of  lymph  on  lower  lobe  of  left  lung. 

In  Case  CXX.  there  v^as  also  a  concurrence  of  gall-stones 
with  cancer  of  the  liver  and  pancreas. 


374  JAUNDICE,  LECT.  X. 

Case   CXX. — Conjunction  of  Gall-stones  and  Cancer  of  Liver  and 
Pan  creas — Jaundice. 

Sarah  H ,  53,  adm.  into  St.  Thomas's  Hosp.  JSTov.  4,  1872. 

Fatber  died  at  70,  and  mother  at  76  ;  causes  of  death  unknown. 
Four  brothers  and  four  sisters  alive  and  well ;  none  dead.  Patient 
had  enjoyed  good  health  until  two  months  before  admission,  when  she 
was  suddenly  seized  with  violent  pain  at  epigastrium  and  between 
shoulders,  attended  by  shivering  and  vomiting.  Pain  was  paroxysmal 
and  lasted  one  week,  and  then  suddenly  ceased.  After  about  a  fort- 
night she  had  a  second  attack  of  pain,  vomiting,  and  rigors,  lasting  for 
a  day  or  two,  but  subsequently  to  this  there  was  no  recurrence  of  these 
symptoms.  On  second  day  of  first  attack  she  was  observed  to  be 
yellow  ;  and  from  then  up  to  admission  jaundice  had  increased  in 
intensity. 

On  admission,  no  pain  and  not  very  emaciated  ;  deep  jaundice ; 
no  itchiness  ;  tongue  slightly  coated  ;  appetite  good  ;  great  flatulence, 
but  no  vomiting ;  four  or  five  loose,  offensive,  clay-coloured  motions  in 
day.  Distinct  fulness  and  tenderness  in  region  of  gall-bladder  ;  this 
could  be  felt  to  project  beyond  anterior  margin  of  liver,  which  Avas  not 
much  enlarged.  Urine  loaded  with  bile-pigment.  Pulse  80,  irregulai* 
and  intermittent ;  heart  healthy. 

Was  ordered  meat  diet,  an  alkaline  mixture,  ajid  a  creasote  pill 
twice  daily  after  meals.  A  few  days  after  admission  patient  began  to 
complain  much  of  pain  across  back.  On  !Nov.  13  there  was  slight 
ascites  and  considerable  oedema  of  both  legs,  the  right  leg  being 
larger  than  left.  On  Nov.  21  the  ascites  had  increased ;  there  was  in- 
duration of  integuments  around  navel,  and  pain  was  so  severe  that  it 
was  necessary  to  have  recourse  to  subcutaneous  injections  of  morphia. 
After  this,  patient  rapidly  sank,  and  died  on  Nov.  26. 

Autopsy. — Peritoneum  contained  two  gallons  of  clear  serum.  Liver 
94  oz.,  yet  it  projected  but  little  beyond  ribs.  Gall-bladder  greatly 
enlarged  and  forming  a  prominent  tumour.  Liver  adherent  to  dia- 
phragm, stomach,  duodenum,  and  pancreas.  Projecting  from  its  surface 
Avere  numerous  nodules  of  cancer  up  to  1^  in.  in  diameter,  very 
vascular,  and  larger  ones  cupped.  Immediately  above  gall-bladder 
was  a  mass  of  cancer,  3  in.  in  diameter,  infiltrating  tissue  of  liver  and 
involving  its  whole  thickness.  Gall-bladder  full  of  pus,  with  more 
than  twenty  gall-.stones,  but  no  bile.  Cystic  duct  almost  obliterated. 
Common  duct,  hepatic  dnct,  and  ducts  inside  liver  all  much  dilated. 
Growing  from  head  of  pancreas  was  a  large  tumour  surrounding  portal 
vein  and  encroaching  on  duodenum  where  bile-duct  enters.  Omentum 
much  thickened  from  cancerous  deposit.  About  a  pint  of  serum  in 
each  pleura.  Both  lungs  studded  with  cancerous  nodules  from  size  of 
a  pin's  head  to  that  of  a  pea,  the  larger  ones  cupped.  Other  organs 
healthy. 


rECT.  X.  FKOM    OBSTEUCTION    OF    BILE-DUCT.  375 

In  former  lectures  I  have  brought  under  your  notice  several 
other  cases  of  jaundice  from  gall-stones.  In  Case  LXY.  (p.  159) 
the  jaundice  resulted  from  inflammation  of  the  biliary  passages 
excited  by  gall-stones  in  the  gall-bladder,  but  there  had  been 
no  history  of  biliary  colic ;  in  Case  LXVI.  (p.  162)  there  was 
jaundice,  v^^ith  enlargement  of  the  liver  and  gall-bladder, 
from  obstruction  of  the  common  duct  by  a  calculus  ;  and  in 
Case  LXXI.  (p.  173)  attacks  of  biliary  colic  and  jaundice  were 
followed  by  pysemic  abscesses  in  the  liver  and  death. 

You  will  remember  also  that,  when  on  the  subject  of  en- 
largements of  the  liver  from  hydatid  tumour,  I  related  to  you 
several  cases  where  the  bile-duct  became  obstructed  by  hydatid 
vesicles  which  had  escaped  from  the  ruptured  parent  hydatid, 
and  that  in  one  of  these  cases  (Case  XXXIV.,  p.  116),  the 
passage  of  hydatid  vesicles  along  the  bile-duct  produced  all 
the  phenomena  resulting  from  the  passage  of  gall-stones. 

I  have  also  in  a  former  lecture  called  your  attention  to 
several  cases  where  jaundice  resulted  from  inflammation  of  the 
bile-ducts  interfering  with  the  flow  of  bile  (see  p.  155). 

The  next  case  is  an  example  of  a  very  rare  form  of  jaundice, 
where  the  cause  was  a  congenital  closure  of  the  bile-duct. 

Case  CXXI. — Jaundice  from  congenital  Closure  of  Bile-duct. 

Esther  W ,  aged  2  months,  was  brought  to  me  by  her  mother 

as  an  out-patient  at  this  (Middlesex)  hospital  on  January  7,  1862.  The 
mother  stated  that  the  child  had  appeared  healthy  when  born,  but  that 
a  few  days  afterwards  she  was  noticed  to  be  unusually  yellow,  and  that 
this  yellowness  had  been  increasing,  while  the  child  had  suffered  from 
diarrhoea  and  had  been  emaciating.  When  first  seen  by  me  child  was 
very  thin,  and  skin  and  conjunctivae  were  of  an  orange-yellow  colour. 
Motions  perfectly  white  and  very  ofi"ensive.  A  teaspoonfal  of  chalk 
mixture,  to  be  taken  two  or  three  times  a  day,  was  all  that  was 
prescribed. 

On  Jan.  21  child  not  quite  so  yellow,  but  thinner,  and  motions  red 
like  brick- dust,  evidently  from  presence  of  blood.  She  had  also  had 
several  attacks  of  slight  epistaxis. 

During  next  week  child  continued  much  in  same  state,  still  losing 
a  little  blood  occasionally  from  nose,  and  getting  gradually  thinner, 
although  there  was  less  diarrhoea. 

On  March  11  it  was  noticed  that  several  black  lumps  had  appeared 
over  chest  and  back.  They  varied  in  size  up  to  three  quarters  of  an 
inch  in  diameter  and  were  considerably  raised  above  surface  ;  they 
were  evidently  due  to  extravasations  of  blood  beneath  skin. 


'ii'J^  JAUNDICE,  lECT.  X. 

On  ]\farcli  25,  mother  stated  that  child  had  been  much  worse  for 
two  previous  days,  vomiting  everything  she  swallowed,  and  vomited 
matters  containing  blood.  The  ecchymoses  on  surface  had  also  in- 
creased both  in  number  and  size. 

Two  days  after  this  child  died,  and  on  careful  dissection  common 
bile-duct  was  found  to  be  completely  obliterated,  its  place  being 
occupied  by  a  small  quantity  of  areolar  tissue.  Gall-bladder  extremely 
small  and  collapsed,  and  contained  only  a  few  drops  of  colourless  fluid. 
The  opening  of  duct  in  duodenum  was  found  with  difficulty,  and  a  probe 
could  not  be  passed  through  it  into  bile-duct.  Liver  jaundiced  mth 
a  few  fibrous  bands  of  adhesion  on  under  surface ;  ducts  dilated ;  in 
other  respects  appeared  normal.  Altered  blood  in  contents  of  bowels, 
and  several  small  extravasations  beneath  mucous  membrane  of  both 
stomach  and  intestines. 

In  a  future  lecture  I  shall  bring  under  your  notice  a  case 
where  jaundice  was  the  result  of  constriction  of  the  duct  from 
peri-hei^atitis  (Lect.  XII.),  and  Case  CXXII.,  of  which  I 
show  you  here  the  specimen,  dissected  by  me  many  years 
ago  while  pathologist  to  the  Middlesex  Hospital,  is  a  rare 
example  of  obstruction  of  the  orifice  of  the  bile-duct  in  conse- 
quence of  its  being  involved  in  the  cicatrix  of  a  duodenal  ulcer. 
In  the  case  from  which  this  preparation  was  obtained  there 
was  painful  enlargement  of  the  gall-bladder  and  jaundice, 
arising  from  obstruction  of  the  duct  caused  apparently  b}"-  the 
cicatrisation  of  a  duodenal  ulcer.  The  contraction  of  the  liver 
in  this  case  was  no  doubt  due  to  the  long  duration  of  the 
obstruction,  the  hepatic  tissue  having  become  atrophied  from 
the  pressure  upon  it  of  the  permanently  distended  bile-ducts. 

Case  CXXII. — Jaundice  from  Obstruction  of  Common  Bile-duct  by 
Cicatrix  of  a  Duodenal  Ulcer — Dilatation  of  Bile-ducts  and  Atrophy 
of  Liver. 

James  B ,  aged  69,  a  coachman,  of  small  frame  and  spare  habit, 

admitted  into  Middlesex  Hospital  on  May  4,  1861.  During  greater 
part  of  his  life  he  had  been  in  habit  of  drinking  a  good  deal,  but  for 
last  seven  years  he  had  been  a  very  steady,  .^ober  man.  With  excep- 
tion of  an  attack  of  acute  bronchitis  nine  years  before,  which  left  him 
'asthmatic,'  he  had  enjoyed  good  health  until  four  months  before  ad- 
mission, when  he  had  been  suddenly  seized  with  acute  pain  in  right 
hypDchondriuin,  vomiting  of  bitter  matter,  and  much  fever.  After  a 
fortnight  skin  became  jaundiced  and  he  had  great  formication.  Jaun- 
dice increased  in  intensity,  but  formication  diminished.    Latterly  he  had 


LBCT.  X.  FEOM    OBSTRUCTION    OF    BILE-DUCT.  377 

suffered  from  palpitation  in  cardiac  region  and  throbbing  in  head, 
and  he  had  lost  both  flesh  and  strength.  At  commencement  of  his 
illness  he  had  been  for  a  fortnight  in  another  hospital,  where  he  had 
been  salivated. 

On  admission,  patient  was  emaciated  and  feeble  ;  pulse  72,  and 
intermitting ;  whole  skin  and  conjunctivae  of  a  bright  lemon-yellow. 
Patient  complained  of  a  dull  pain  in  region  of  liver,  dulness  on  percus- 
sion of  which,  appeared  considerably  increased,  measuring  upwards  of 
5  in.  in  right  mammary  line.  On  more  careful  examination,  it 
was  ascertained  that  this  enlargement  was  limited  to  situation  of  gall- 
bladder, and  that  posteriorly  and  laterally  hepatic  dulness  was  dimi- 
nished. Tongue  had  a  yellowish  coat.  He  had  no  bitter  taste,  but 
sense  of  taste  was  in  a  great  measure  abrogated  ;  no  appetite  ;  bowels 
confined,  motions  being  nearly  white.  Urine  dark,  like  porter,  and 
contained  much  bile-pigment.  Bladder  had  to  be  evacuated  by 
catheter.  Over  botli  lungs  sonorous  rhonchi  could  be  heard,  and  ex- 
piration was  proloDged.  He  still  complained  of  itching  of  skin  at 
night. 

Patient  was  treated  with  alkalies,  ammonia,  vegetable  bitters,  and 
stimulants  ;  but  prostration  rapidly  increased,  a  bed-sore  appeared 
over  sacrum  ;  tongue  became  dry  and  brown,  and  sordes  collected  on 
teeth ;  motions  became  very  dark  from  presence  of  blood ;  pulse  rose 
to  90  ;  signs  of  bronchitis  increased,  and  for  several  days  before  death, 
which  occurred  on  May  19,  there  was  low  muttering  delirium. 

At  autopsy,  liver  small,  pale,  and  flabby ;  lower  margin  did  not 
reach  so  far  as  edge  of  ribs.  Gall-bladder  about  four  times  normal 
size,  and  filled  with  a  colourless  flaky  fluid  destitute  of  any  tint  of 
bile.  Cystic,  hepatic,  and  common  ducts  all  enormously  dilated, 
common  duct  being  larger  than  one's  finger,  and  all  filled  with  a 
colourless  fluid  similar  to  that  in  gall-bladder.  Bile-ducts  also  in 
interior  of  liver  greatly  dilated  as  far  even  as  outer  surface,  and  filled 
with  a  similar  fluid,  which  flowed  out  when  liver  was  cut  into.  No 
calculus  in  gall-bladder  nor  in  any  of  ducts,  but  orifice  of  common  duct 
in  duodenum  completely  blocked  up.  Coats  of  bowel  at  this  part 
dense  and  considerably  thickened,  forming  a  nipple-like  prominence 
about  size  of  a  hazel-nut,  and  around  this  mucous  membrane  had  a 
radiated,  puckered  appearance,  as  if  from  cicatrisation  of  an  ulcer. 
No  ulcers  nor  cicatrices  elsewhere  in  bowels,  and  no  evidence  of  morbid 
deposit  in  head  of  pancreas  nor  in  adjacent  glands,  but  pancreatic  ducts 
much  dilated.  Secreting  tissue  of  liver  of  an  olive-yellow  colour  and 
flabby,  but  not  friable  ;  outlines  of  lobules  obliterated,  and  on  micro- 
scopic examination  much  granular  and  oily  matter  was  discovered, 
but  secreting  cells  had  mostly  disappeared.  Much  atheroma  of  aorta 
and  of  valves  of  heart.  Lungs  presented  characters  of  bronchitis  and 
emphysema  of  old  standing.  Prostate  enlarged  and  bladder  contracted, 
its  mucous  membrane  being  very  hypertemic,  encrusted  with  flakes  of 


378  JAUNDICE,  LECT.  X. 

diphtheritic  exudation  as  large  as  a  shilling  ;  kidneys  granular,  and 
pelves  and  calices  dilated. 

When  lecturing  on  the  subject  of  enlargements  of  the  liver 
from  cancer,  I  brought  under  your  notice  several  examples 
of  this  disease  in  which  there  was  jaundice.  In  one  (Case 
LXXXVII.,  p.  220)  there  was  unfortunately  no  post-mortem 
examination  ;  in  another  (Case  LXXXV.  p.  216)  the  jaundice 
was  due  to  compression  of  the  common  duct  b}'  a  dense  mass 
of  areolar  tissue  and  enlarged  cancerous  glands  in  the  portal 
fissure. 

In  Case  CXXIII.  the  jaundice  was  due  to  compression 
of  the  common  bile-duct  by  a  mass  of  cancerous  glands  in  the 
fissure  of  the  liver  secondar}'^  to  cancer  of  the  stomach.  It  was 
notable  that  at  first  the  patient  gained  weight  under  treatment. 

Case  CXXIII. — Cancer  of  Stomach  and  lAver,  Jaundice,  and  Ascites. 

Charles  D ,  labourer,  aged  58,  adm.  into  Middlesex  Hosp.  Sept. 

10,  1869.  No  family  history  of  cancer.  For  some  years  had  been 
liable  to  attacks  of  diarrhoea  from  slight  causes,  but  with  this  exception 
had  enjoyed  good  health  until  four  months  before  admission,  when  he 
began  to  suffer  from  pain  at  epigastrium  and  flatulent  distension  after 
meals,  and  he  had  occasional  retching  in  the  morning,  but  never 
brought  up  his  food.  These  symptoms  increased  in  severity,  and  soon 
patient  lost  all  appetite  for  food  and  became  rapidly  emaciated.  After 
a  month  jaundice  appeared,  and  was  at  first  attended  with  intolerable 
itchiness  of  skin.  Quite  recently  his  legs  had  become  swollen  after 
walking. 

On  admission  patient  was  very  thin ;  weighed  only  89  lbs.  (weight 
had  never  exceeded  112  lbs.).  Deep  jaundice  of  skin  and  conjunctivae, 
and  moderate  oedema  of  both  legs.  Liver  enlarged,  in  r.  m,  1.  measur- 
ing b^  in.  and  extending  1^  in.  beyond  ribs ;  its  surface  in  epigastrium 
somewhat  tender,  with  a  tolerably  distinct  projecting  nodule,  just  above 
umbilicus,  also  a  distinct  projection  from  edge  of  liver  corresponding 
to  gall-bladder.  Abdominal  veins  dilated ;  slight  ascites ;  splenic 
dulness  not  increased  ;  girth  at  umbilicus  27^^  in.  Tongue  white  ; 
immediately  after  eating  has  much  pain  at  epigastrium,  lasting  for  half 
an  hour ;  no  vomiting  ;  bowels  regular ;  white  stools.  Urine  loaded 
w^ith  bile-pigmont  and  lithates  ;  no  albumen.     Sleeps  well. 

Under  use  of  nitro-muriatic  acid  and  bitter  tonics,  patient's  ap- 
petite somewhat  improved,  and  in  last  fortnight  of  September  he  gained 
31bs.  in  weight.  Pain  at  epigastrium,  however,  increased  ;  on  Sept.  27 
another  tender  nodule  could  be  felt  just  below  ensiform  cartilage,  and  on 
Oct.  4  a  third  was  appreciable  a  little  to  right  of  second  ;  bowels  be- 


LECT.  X.  FROM    OBSTRUCTION"    OP    BILE-DUCT.  379 

came  loose,  ascites  and  oedema  of  legs  increased,  and  jaundice  persisted. 
On  Oct.  15  girth  at  umbilicus  was  31  in.,  and  patient  being  much 
weaker  and  thinner  left  hospital  for  his  own  home  at  Castle 
Hedingham,  where  he  died  on  Nov.  8. 

A  post-mortem  examination  was  made  by  Mr.  E.  Andrews,  to  whom 
I  am  indebted  for  following  particulars.  Three  quarts  of  fluid  in 
peritoneum.  Stomach  contracted,  its  walls  infiltrated  with  much  can- 
cerous matter  deposited  between  mucous  and  muscular  coats  ;  orifices 
not  involved,  and  mucous  membrane  not  ulcerated.  Left  lobe  of  liver 
adherent  to  diaphragm,  and  scattered  through  it  several  cancerous 
nodules,  some  of  which  projected  from  surface.  In  fissure  of  liver  was 
a  large  mass  of  hard  cancerous  matter,  compressing  portal  vein  and 
blocking  up  cystic  and  common  bile-duct.     Thoracic  organs  healthy. 

In  the  three  cases  which  follow,  the  jaundice  was  due  to  a 
cancerous  tumour  which  seemed  to  originate  in  the  head  of  the 
pancreas  ;  but  in  Case  CXXIV.,  as  you  will  see  by  this  prepara- 
tion (Middlesex  Hospital  Mus.  Cat.,  Series  IX.  No.  18),  the 
obstruction  of  the  bile-duct  was  due  to  an  independent  cancer- 
ous growth  springing  from  its  lining  membrane ;  and  in  the 
two  others  (Cases  CXXV.  and  CXXYI.)  it  was  produced  by  a 
mass  of  cancerous  matter  in  the  portal  fissure. 

Case  CXXIV. — Jaundice  from  Obstruction  of  Common  Bile-duct  by  a 
cancerous  Groivth  from  its  lining  Membrane — Dilatation  of  Bile-ducts 
and  enlargernent  of  Gall-bladder — Cancerous  Growth  in  Bancreas. 

The  patient  from  whose  body  this  preparation  was  obtained  was  a 
cabinet-maker,  aged  36,  who  was  admitted  into  this  (Middlesex)  hospital 
on  Sept.  1,  1857.  His  illness  had  commenced  on  June  1  with  vomiting 
and  purging,  followed  after  three  or  four  weeks  by  intense  jaundice, 
dark  urine,  and  white  stools.  He  had  no  symptoms  of  gall-stones,  but 
there  was  a  settled  dull  pain  in  region  of  liver,  which  was  enlarged  and 
tender.  He  complained  of  loss  of  appetite,  thirst,  and  lassitude.  He 
had  been  treated  at  first  with  mercurials,  and  subsequently  with  nitro- 
muriatic  acid  and  taraxacum  and  saline  aperients  ;  and  by  middle  of 
August  liver  seemed  reduced  to  nearly  its  normal  size  and  was  fi-ee 
from  tenderness,  but  gall-bladder  was  enlarged  and  seemed  to  be  about 
size  of  a  small  pear,  and  jaundice  was  increased. 

When  admitted  into  hospital,  patient  had  intense  jaundice,  and 
urine  was  loaded  with  bile-pigment,  of  which  feeces  contained  not  a 
trace.  Liver  was  of  natural  size,  but  gall-bladder  could  be  felt  reach- 
ing as  low  as  umbilicus  and  was  seat  of  considerable  tenderness.  There 
was  much  tympanites,  but  no  ascites  nor  enlargement  of  abdominal 
veins.  Patient  was  very  emaciated  and  low-spirited,  had  no  appetite, 
and  passed  sleepless  nights. 


380  JAUNDICE,  LECT.  X, 

Iodide  of  potassium,  bicarbonate  of  potash,  mineral  acids,  taraxacum, 
gentian,  quinine,  and  nitro-liydroehloric  acid  baths  and  lotions  were 
tried  in  turn,  but  nothing  made  any  impression  on  the  disease.  The 
tumour  corresponding  to  gall-bladder  increased  in  size  and  became 
more  tender,  and  about  three  weeks  after  admission  patient  became 
suddenly  unconscious  and  had  symptoms  of  rapid  dissolution,  with 
muttering  delirium.  These  symptoms  gradually  subsided  in  coui-se  of 
an  hour  and  did  not  recur,  but  patient  gradually  sank  and  died  on 
Oct.  21. 

Autopsy. — Gall-bladder  projected  3  in.  beyond  anterior  margin  of 
liver,  and  extended  to  within  an  inch  of  anterior  superior  spinous  pro- 
cess of  ilium  ;  its  length  vvas  altogether  7^  in.  Its  coats  were  at- 
tenuated, and  its  inner  sui'face  had  lost  its  reticular  appearance  and 
was  rough,  red,  and  granular.  It  contained  15  fluid  oz.  of  a  pale 
tui'bid  fluid,  like  barley-water,  which  on  standing  deposited  numerous 
small  particles  of  inspissated  bile.  The  fluid  was  alkaline  ;  its  specitic 
gravity  was  1010 ;  and  it  contained  numerous  very  large  cells 
presenting  from  two  to  four  nuclei  with  nucleoli,  besides  flakes  of 
tesselated  epithelium,  granular  matter,  &c.  Cystic  and  greater  part  of 
common  bile-duct  also  much  dilated,  latter  being  large  enough  to  admit 
a  man's  thumb,  and  on  cutting  into  liver  a  large  quantity  of  white 
fluid  like  that  in  gall-bladder  escaped  from  greatly  dilated  biliary  duets. 
Liver  weighed  60  oz.  ;  it  was  of  a  dark  olive-green  colour ;  outline 
of  lobules  distinct.  On  tracing  common  bile-duct  to  bowel,  it  may  be 
seen  in  the  specimen  to  be  obstructed  by  an  exuberant  growth  of 
medullary  cancer  growing  from  its  inner  surface,  and  extending  for 
about  2  in.  upwards  from  duodenum.  Before  duct  was  slit  up,  a  probe 
could  be  passed  with  difficulty  from  duodenal  orifice  through  obstruc- 
tion. On  cutting  into  growth,  a  glairy  juice  exuded,  which  contained 
large  compound  nucleated  cells,  similar  to  those  found  in  fluid  in  gall- 
bladder, and  free  nuclei.  Head  of  pancreas  was  inv^olved  in  a  growth 
larger  than  an  orange,  which  on  section  presented  a  medullary  ap- 
pearance and  jaelded  a  copious  thick,  milky  juice,  containing  many 
large  nuclei,  but  no  mother-cells.  This  tumour  had  compressed  bile- 
ducr,  but  did  not  encroach  upon  its  walls,  and  growth  in  duct 
appeared  to  have  arisen  independently.  Heart  weighed  only  ti  oz. 
All  organs  and  tissues  of  body  deeply  jaundiced,  but,  with  exceptions 
mentioned,  in  other  respects  healthy.  Contents  of  bowels  devoid  of 
bile-pignieut. 


Case  CXXV. — Cancer  of  Pancreas  and  of  Gall-bladder — Jaundice  fnnn 
Obstruction  of  Bile-duct. 

At  end  of  May   1866,  I  was  consulted  in  reference  to  case  of  Mr. 

D ,  a  gentleman  between  60  and  70  years  of  age,  who  had  jaundice. 

His  illness  had  commenced  about  beginning  of  Jajiuury,  with  symptoms 


LECT.  X.  FROM    OBSTRUCTION    OF    BILE-DUCT.  38 1 

of  broncliitis,  loss  of  appetite,  and  restless  Bights.  On  one  of  last 
days  in  February  he  had  been  exposed  to  severe  cold,  and  next  morn- 
ing he  awoke  with  intense  nausea  and  retching,  which  continued  till 
night.  Slight  febrile  symptoms  followed  ;  pulse  rose  ten  beats  above 
its  average  ;  appetite  was  capricious,  and  bowels  required  aperients. 
He  rapidly  lost  flesh,  and  about  middle  of  April  jaundice  appeared. 
His  symptoms  at  time  I  was  consulted  were  as  follows  : — Deep  jaun- 
dice of  skin  and  conjunctivas.  Urine  scanty  and  very  dark,  and  con- 
tained a  large  quantity  of  bile-pigment.  Slight  tendency  to  diarrhoea  ; 
motions  devoid  of  bile,  of  a  leaden  hue  and  very  offensive,  but  some- 
times contained  a  small  quantity  of  blood  from  piles.  Liver  appeared 
to  be  quite  within  its  normal  limits,  but  there  was  occasional  uneasi- 
ness in  right  hypochondrium,  and  decided  tenderness  with  slight 
hardness  about  situation  of  gall-bladder ;  superficial  veins  of  abdomen 
slightly  enlarged.  Pulse  72  ;  increasing  emaciation  and  debility,  with 
decreasing  appetite  and  occasional  retching ;  countenance  exhibited 
an  anxious,  cachectic  aspect. 

The  treatment  consisted  in  effervescing  draughts  with  hydrocyanic 
acid  and  Battley's  liquor  opii,  and  in  rubbing  in  externally  iodide  of 
potassium  ointment. 

About  beginning  of  June  vomiting  became  more  urgent ;  almost 
everything  that  was  swallowed  was  rejected ;  pain  increased  ;  tongue 
became  thickly   furred   and   brown ;  and  emaciation  increased  daily. 

After  three  days  of  unconsciousness  and  low  delirium,  Mr.  D died 

on  June  19. 

A  post-mortem  examination  was  made  by  Mr.  Moreton  of  Tarvin, 
Cheshire,  to  whom  I  am  mainly  indebted  for  following  particulars,  and 
for  forwarding  to  me  some  of  parts  for  examination.  Firm  bands  of 
adhesion  connected  whole  surface  of  liver  to  surrounding  parts.  'No 
ascites.  Gall-bladder  about  size  of  a  hen's  egg,  its  walls  greatly 
thickened  from,  cancerous  deposit,  and  its  cavity  containing  about  a 
teaspoonful  of  thick  fluid  like  cream  mixed  with  blood.  Opening  of 
gall-bladder  into  cystic  duct  closed  ;  and  both  cystic  and  common  bile- 
duct  were  imbedded  in,  and  obstructed  by,  a  mass  of  cheesy,  cancerous 
matter.  N'o  cancerous  deposits  in  liver,  but  in  head  of  pancreas  was 
a  mass  of  cancer  as  lai-ge  as  a  small  orange.  All  of  these  deposits  gave 
on  section  a  ci'eamy  juice,  containing  usual  cellular  elements  of  cancer. 


Case  CXXVI. — Jaundice  fi'om  Obstruction  of  Bile-duct  hy  Cancer 
originating  in  head  of  Pancreas. 

Mary  C ,  aged  64,  adm.  into  St.  Thomas's  Hosp.  Nov.  2,  187-5. 

Mother  had  died  at  93 ;  father  52,  and  two  sisters,  18,  and  36,  had 
died  of  consumption  ;  two  brothers  alive,  70,  and  60.  No  family  history 
of  cancer,  and  habits  had  been  temperate.  For  several  years  had 
suffered  from  aching  pains  in  back  and  been  easily  fatigued,  and  duriuo- 


382  JAUNDICE,  LECT.  X. 

same  period  she  had  suffered  from  nausea  and  sometimes  from  vomit- 
ing, usually  before  breakfast,  and  from  occasional  attacks  of  pain  be- 
tween umbilicus  and  right  ribs.  For  ten  months  she  had  been  losing 
flesh,  pain  and  sickness  had  been  more  frequent,  and  bowels  had  been 
constipated.  Ten  weeks  before  admission  she  had  an  attack  of  very 
severe  pain  in  upper  part  of  abdomen  lasting  24  hours,  and  shortly 
after  this  she  became  jaundiced  and  skin  was  very  itchy.  After  ap- 
pearance of  jaundice  she  became  more  rapidly  emaciated,  and  two 
weeks  before  admission  legs  began  to  swell. 

On  admission,  weak,  emaciated,  and  deeply  jaundiced.  Urine 
loaded  with  lithates  and  bile-pigment.  Stools  light  and  contain  no 
bile,  but  stated  to  be  sometimes  very  dark.  Tongue  red,  smooth,  and 
dry ;  appetite  bad  ;  food  gives  her  pain,  and  on  three  occasions  since 
jaundice  has  vomited  ;  bowels  costive.  Liver  much  enlarged  in  every 
direction,  measuring  vertically  in  right  nipple  line  8  in.,  of  which 
o  below  ribs  ;  surface  hard,  nodulated,  and  slightly  tender  ;  has  at 
times  great  pain  in  liver,  which  may  last  several  hours.  Slight  ascites 
and  some  oedema  of  legs,  more  of  left  than  of  right. 

Was  ordered  small  doses  of  nux  vomica,  with  occasional  anodynes 
and  a  light  diet.  For  two  or  three  days  bowels  were  relaxed  and 
motions  light-coloured.  On  Nov.  9  bi'eathing  became  embarrassed 
and  there  was  some  cough.  These  symptoms  rapidly  got  worse  ;  lips 
livid,  and  all  signs  of  consolidation  at  lower  and  back  jiart,  first  of 
right,  and  then  of  left  lung.     On  Nov.  16,  died  asphyxiated. 

Autopsy. — Cancer  of  head  of  pancreas  and  of  glands  in  hilus  of 
liver,  growing  into  duodenum  and  involving  common  and  C3'stic  duct. 
Secondary  growths  in  liver.  Extensive  hypostatic  consolidation  of 
lower  and  back  part  of  both  lungs,  with  several  patches  of  lobular 
pneumonia  in  lower  lobe  of  right,  but  no  sign  of  new  growth. 
Kidneys  somewhat  granular. 

In  the  three  following  cases  jaundice  was  due  to  cancer 
taking  its  origin  in  the  duodenum.  The  patient  whose  case  I 
will  first  relate  to  you  was  under  3-our  observation  for  eight 
months,  and  you  will  remember  how  frequently  I  called  j'our 
attention  to  the  distressing  itchiness  fruui  which  he  suffered. 
He  was  also  the  subject  of  boils  and  carbuncles  and  of  yellow 
vision  (p.  821)  ;  but  the  main  source  of  interest  in  his  case 
Avas  the  cause  of  the  obstruction,  about  which  we  often  specu- 
lated. The  improvement  which  at  one  time  took  place  in  his 
appearance  and  weight  seemed  to  negative  cancer  of  the 
pancreas  or  duodenum,  or  indeed  cancer  of  any  other  organ. 
Moreover  the  duodenal  tumour,  you  will  observe,  occupied 
exactly  the  position  of  the  gall-bladder,  so  that,  although  there 
was  no  clear  historj'  of  biliary  colic,  the  most  probable  causes  of 


LECT.  X.  FEOM    OBSTRUCTION    OF    BILE-DUCT.  383 

obstruction,  on  the  man's  first  admission,  appeared  to  be  an 
impacted  gall-stone,  a  simple  stricture  of  the  duct,  or  closure 
of  its  orifice  by  the  cicatrix  of  a  duodenal  ulcer.  Even  at  a 
later  stage,  the  rigors,  pyrexia,  and  night-sweats  left  it  doubt- 
ful whether  the  rapid  enlargement  and  nodulated  condition  of 
the  liver  and  the  severe  paroxysms  of  pain  might  not  result 
from  pya^mic  abscesses  of  the  liver,  secondary  to  ulceration  of 
the  bile-duct  from  the  pressure  of  a  large  gall-stone  ;  and  this 
view  received  confirmation  from  the  circumstance,  that  the 
advent  of  these  serious  symptoms  was  accompanied  by  a  disap- 
pearance of  the  jaundice  and  itchiness  after  a  duration  of  seven 
months. 

Case  CXXVII. — Cancer  of  Duodenum — Jaundice  from  Closure  of  Bile- 
duct — Sloughing  of  Tumour  and  Disappearance  of  Jaundice — *Se- 
conda,ry  Cancer  and  Abscesses  of  Liver. 

William  M ,  aged  50,  a  porter,  but  formerly  a  fireman,  admitted 

into  Middlesex  Hosp.  under  my  care  on  Xov.  26,  1867.  Twelve  years 
before  admission,  he  had  suffered  from  bronchitis,  and  four  years 
before  he  had  been  laid  up  for  seven  weeks  with  rheumatic  fever. 
For  ten  years  he  had  been  subject  to  piles,  and  had  occasionally  lost  a 
good  deal  of  blood  from  them.  He  had  been  in  habit  of  drinking  a 
good  deal  of  beer,  but  he  had  never  been  a  spirit- drinker.  There  was 
no  history  of  cancer  in  his  family  ;  his  father  was  alive,  aged  83,  his 
mother  had  died  at  63  from  rupture  of  a  blood-vessel.  Six  weeks 
before  admission,  he  noticed  his  urine  to  be  very  dark,  and  his  motions 
pale,  and  that  he  was  becoming  thinner  and  weaker,  and  about  same 
time  he  began  to  suffer  from  itchiness  of  skin.  After  about  a  fortnight 
he  found  his  skin  becoming  yellow,  and  he  often  awoke  in  night  with 
severe  pain  at  pit  of  stomach,  alleviated  by  friction,  which  seemed  to 
bring  up  a  quantity  of  gas.  Skin  and  urine  gi^adually  became  darker, 
and  on  one  occasion,  a  fortnight  before  admission,  he  vomited  about  a 
pint  of  clear  watery,  tasteless  fluid. 

On  admission,  patient  was  thin,  and  had  very  deep  jaundice  of 
skin  and  conjunctivse,  but  chief  complaint  was  of  intense  itchiness 
over  whole  body,  though  most  severe  in  palms  of  hands  and  soles  of 
feet,  which  kept  him  awake  at  night.  Skin  was  marked  by  numerous 
scratches,  but  no  eruption.  Urine  very  dark  like  porter,  and  yielded 
reaction  of  bile-pigment  in  a  marked  degree,  but  contained  no  albu- 
men. No  feeling  of  pain  or  tenderness  in  region  of  liver,  which  did 
not  project  beyond  edge  of  ribs,  and  which  did  not  seem  to  be  mate- 
rially altered  in  size,  dulness  in  right  mammaiy  line  being  3^  in. 
and  man  being  of  small  build  and  short  stature.  Corresponding  to 
gall-bladder,  however,  hepatic  dulness  seemed  to  project  about  half 


384  JAUNDICE,  LECT,  X. 

an  inch  from  general  boundary  line.  Splenic  dulness  not  increased. 
No  ascites,  no  appreciable  abdominal  tumour,  no  enlargement  of 
abdominal  veins,  and  but  slight  tympanitic  distension  of  bowels. 
Tongue  moist  and  coated  white.  A  bitter  taste,  especially  in  morning ; 
nausea  and  loss  of  appetite  ;  bowels  regular  ;  motions  clay-coloured. 
Cardiac  and  respiratory  symptoms  normal,  except  that  pulse  was  only 
52.  Temperature  97'5°.  TVeight  on  Oct.  2,  before  he  began  to  be  ill, 
had  been  132  lbs.  ;  a  few  days  after  admission  it  was  116  lbs. 

He  was  ordered  a  mixture  with  bicarbonate  of  soda  (gr.  x)  and 
spirit  of  chloroform  (ni^xx)  three  times  a  day,  and  a  henbane  draught 
at  night. 

A  few  days  after  admission  it  was  ascertained  that  patient  had 
yellow  vision  ;  everything  white  appeared  to  him  yellow.  ConjunctivaB 
were  at  same  time  considerably  injected.  Yellow  vision  disappeared 
about  end  of  December  and  did  not  recur,  although  no  change  took 
place  either  in  jaundice  or  in  amount  of  blood  in  conjunctival  vessels. 

Henbane,  Indian  hemp,  opium,  subcutaneous  injections  of  morphia, 
ox-bile,  benzoic  acid,  and  warm  baths  were  resorted  to  in  succession, 
but  failed  to  relieve  itchiness.  Patient  suflfered  also  much  from 
attacks  of  flatulent  colic,  which  appeared  to  be  relieved  by  a  pill  with 
creasote  (liy)  and  galbanum  (pil.  galb.  co.  gr.  iij),  taken  twice  a  day, 
and  subsequently  by  the  confectio  terebinthiuaB.  Pills  of  ox-bile  were 
tried  without  any  result.  On  Dec.  13,  and  again  on  Dec.  28,  he 
vomited  breakfast. 

On  Dec.  30,  following  note  was  entered  in  case-book.  '  For  first 
time  there  is  felt  what  appears  to  be  a  deep-seated,  hard  tumour,  about 
size  of  a  walnut,  1^  in.  above  and  to  right  of  umbilicus,  which  is  not 
at  all  tender  ; '  and  on  Feb.  10  there  is  this  additional  note  :  '  Tumour 
formerly  noted  is  more  distinct :  it  appears  to  be  about  size  of  a  small 
orance,  and  situated  to  right  of  umbilicus.  It  is  hard,  and  its  surface 
is  slightly  lobulated  but  not  at  all  tender.  It  is  distinctly  movable 
and  appears  to  be  continuous  above  with  liver,  with  which  it  is  con- 
nected in  precisely  situation  of  gall-bladder.  Its  lower  extremity  is 
fully  2|  in.  below  general  outline  of  liver.' 

The  itching  continued  to  be  very  intense  and  was  source  of  great 
distress  ;  but  on  three  different  occasions,  viz.  on  Jan.  20,  Feb.  8,  and 
March  18,  it  was  at  once,  and  for  many  days,  relieved  by  a  mixture 
containing  10  gr.  of  the  bicarbonate  of  potash  with  10  gr.  of  the 
nitrate  of  potash,  taken  three  tiines  a  day.  During  last  fortnight 
of  February  patient  had  many  attacks  of  severe  abdominal  pain,  often 
lasting  for  several  hours  and  relieved  by  eructations  of  gas  and  fluid. 
On  Feb.  26  he  vomited  food.  Abdomen  about  this  time  became 
moderately  distended  from  tympanites.  From  first  his  bowels  had 
been  open  two,  three,  or  four  times  a  day,  motions  being  of  fair  con- 
sistence, but  clay-coloured  and  very  offensive.  Jaundice  and  colour  of 
urine  varied  in  intensity  from   time  to  time,  latter  being  sometimes 


LECT,  X.  FROM    OBSTRUCTIOISr    OF    BILE-DUCT.  385 

almost  black  from  amount  of  bile-pigment.  Appetite  failed  entirely, 
but  was  considerably  improved  by  quinine  pills  ordered  on  Feb.  12. 
He  continued  to  lose  weight  until  March  4,  when  he  weighed  only  105 
lbs.,  being  a  loss  of  11  lbs.  since  admission  ;  after  this  his  appearance 
improved  somewhat,  and  on  April  1  he  had  gained  3  lbs.  About 
end  of  January  he  suffered  for  about  a  week  from  small,  but  very 
painful,  boils  in  meatus  of  left  ear.  At  beginning  of  March  a  crop  of 
small  painful  boils  appeared  on  back  part  of  scalp,  and  at  end  of 
March  a  large  carbuncle  formed  over  occiput  and  upper  part  of  neck, 
on  account  of  which  he  was  transferred  for  three  weeks  to  one  of  the 
surgical  wards. 

May  1,  1868. — Condition  now  is  as  follows.  Appearance  is  on 
whole  improved  and  he  has  gained  5^  lbs.  in  weight  since  March  4. 
Jaundice  decidedly  less  and  urine  contains  less  bile-pigment,  but 
motions  still  clay-coloured  without  a  trace  of  bile.  Itchiness  has 
been  more  distressing  than  ever  since  taking  a  mixture  containing 
nitric  acid  and  bark.  Tumour  has  undergone  little  change  since  Feb. 
10  ;  it  is  still  hard  and  painless.  Area  of  hepatic  dulness  is  decidedly 
less  than  on  admission.  Less  tympanites  and  no  ascites.  Appetite 
better ;  bowels  still  open  two  or  three  times  a  day. 

May  27.- — Has  gained  7  lbs.  in  weight  since  March  4.  Still 
suffers  much  from  itchiness,  but  jaundice  is  less  and  urine  paler  than 
since  admission.  For  a  week  has  taken  three  times  a  day,  two  hours 
after  meals,  a  gelatine  capsule  containing  three  grains  of  ox-o-all, 
but  motions  still  clay-coloured  and  scarcely  darker  than  they  were 
before. 

J^me  6. — Two  days  ago  had  a  very  severe  attack  of  abdominal 
pain,  lasting  for  two  hours,  and  accompanied  by  vomiting,  perspira- 
tion, coldness  of  surface,  and  weak  pulse.  General  condition  remains 
the  same,  and  no  change  in  colour  of  motions. 

After  this  patient  again  began  to  lose  flesh  (June  9,  weight  108  lbs.)  ; 
he  became  much  weaker  and  suffered  from  epigastric  pain  and  a 
burning  pain  in  hands.  On  June  14  he  began  to  vomit  food,  and 
next  day  motions  were  black,  as  from  presence  of  blood.  On  Jane  19 
he  was  scarcely  able  to  walk,  and  tumour  was  noted  as  larger  and 
somewhat  more  to  right.  On  June  25  he  vomited  frothy  matter 
containing  much  sarcina,  and  urine  contained  a  small  quantity  of 
albumen  and  numerous  crystals  of  oxalate  of  lime.  On  June  30  he 
again  vomited  much  sarcina ;  liver  appeared  to  be  larger  and  its 
surface  in  epigastrium  was  distinctly  nodulated.  Vomiting*  of  sarcina 
and  melfena  continued ;  prostration  and  emaciation  rapidly  increased, 
but  jaundice  was  much  less  and  only  very  little  bile  in  urine  ;  and  on 
July  17  lower  edge  of  liver  reached  to  within  1^  in.  of  umbilicus, 
he  had  had  a  distinct  rigor  and  there  was  now  much  pyrexia, 
pulse  having  risen  from  60  to  96,  and  temperature  being  104"  75°  ;  per- 
spirations during  sleep  ;  some   osdema  of  feet.     On  July  19  distinct 

0  0 


386  JAUNDICE,  LECT.  X. 

bulo-ino-at  epigastrmm ;  lower  edge  of  liver  reached  quite  to  umbilicus, 
and  hepatic  dulness  in  r.  m.  1.  measured  8  in.  On  July  23  weight 
only  92^  lbs.  Pyrexia  and  perspirations  continued  ;  and  on  July  26 
diarrhoea  with  distinctly  bilious  motions  ;  there  had  been  no  itchiness 
for  three  Aveeks.  On  July  29  another  severe  rigor  with  intense 
epigastric  pain  and  ci-amps  in  limbs.  Pain  at  epigastrium  recurred, 
frequently,  and  patient  slowly  sank  until  death  on  Aug.  3.  During 
last  week  of  life  jaundice  scarcely  appreciable  and  urine  pale  and 
clear. 

Aidopsy. — Liver  greatly  enlarged,  reaching  down  to  umbilicus,  and 
studded  with  numei'ous  masses  of  soft  cancer  up  to  size  of  a  walnut ; 
some  flakes  of  recent  lymph  on  its  under  surface.  Below  right  lobe 
was  a  rounded,  tumour  of  size  of  an  orange  ;  this  occupied  situation 
of  o-all-bladder,  but  was  unconnected  with  it,  and  originated  in  coats 
of  duodenum.  Corresponding  to  this  tumour,  on  mucous  surface  of 
duodenum,  was  a  cancerous  ulcer,  commencing  2  in.  beyond  pylorus 
and  extending  downwards  for  2^  in.  Substance  of  tumour  was  made 
up  of  medullaiy  cancer.  Common  bile-duct  large  enough  to  admit 
finger,  but  yet  water  could  be  injected  from  it  into  duodenum  through  a 
ragged  sloughy  openiug  iu  ulcer.  Gall-bladder  contained  an  ounce  of 
thin  bilious  fluid,  but  no  calculus.  Bile-ducts  in  interior  of  liver  much 
dilated,  and  many  of  them  seemed  to  terminate  in  small  abscesses  con- 
taining  thick  yellow  pus.  Pancreatic  ducts  also  dilated.  Kidneys 
congested.     All  other  organs  healthy. 

Case  CXXVIII. — Cancer  of  Duodenu7n  and  Stomach — Secondary 
Deposits  in  Liver  etc. — Jaundice  and  Ascites. 

Frederick  R ,  a  painter,  aged   38,  adm.  into  Middlesex  Hosp. 

Peb.  14,  1870.  No  family  history  of  cancer.  Until  nearly  three  years 
before  admission,  when  he  had  an  attack  of  delirium  tremens,  had 
been  intemperate.  At  beginning  of  1868  had  an  attack  of  soretliroat 
without  eruption,  but  followed  by  desquamation  of  skin.  On  recover- 
ing from  this,  first  began  to  suffer  from  pain  in  epigastrium  and  occa- 
sional vomiting,  coming  on  usually  two  or  three  hours  after  food,  and 
these  symptoms  had  persisted  ever  since  with  increasing  severity.  In 
Aug.  1869  first  noticed  a  hard  and  somewhat  tender  swelling  in  upper 
part  of  abdomen,  which  had  continued  to  increase  in  size.  Since 
middle  of  Dec.  1869  had  suffered  much  from  pain  with  numbness, 
shooting  from  right  side  of  abdomen  down  along  front  and  inside  of 
thigh,  and  for  one  month  this  pain  had  been  so  severe  as  to  keep  him 
awake  at  night.  For  two  years  he  had  been  steadily  losing  flesh,  and 
had  suffered  at  times  from  diarrhoea  and  hasmorrhoids.  For  six  weeks 
before  admission  had  kept  his  bed. 

On  admission,  very  emaciated ;  pains  above  referred  to  persistent. 
Pain  down  right   thigh  is  increased  when  he  lies   on  right  side,  and 


LECT.  X.  FROM    OBSTRUCTION    OF    BILE-DUCT.  T,8y 

wlien  lie  lies  on  left  side  there  is  an  uncomfortable  feeling  of  dragging 
about  liver.  Is  most  comfortable  when  lie  lies  on  back.  Can  retain 
beef-tea  and  bread  in  small  quantity,  but  meat  and  most  solid  foods 
are  rejected ;  vomiting  comes  on  from  one  to  several  hours  after  meals. 
Tongue  moist  and  white ;  no  appetite  ;  bowels  have  been  costive  for 
last  six  weeks,  and  have  not  been  opened  for  four  days.  Hepatic 
dulness  in  r.  m.  1.  6|-  in. ;  to  right  of  middle  line  liver  is  smooth  and 
not  tender,  but  in  left  side  of  epigastrium  is  a  hard,  tender,  nodulated 
mass,  about  size  of  large  orange,  apparently  continuous  with  left  lobe 
of  liver,  but  slightly  movable.  Splenic  dulness  not  increased.  No 
jaundice,  no  ascites,  and  no  swelling  of  legs.  Pulse  84 ;  thoracic 
organs  healthy.  Urine  copious,  clear,  1012,  and  contains  neither  bile- 
pigment  nor  albumen. 

Under  use  of  bismuth  and  hydrocyanic  acid,  and  of  creasote  and 
subcutaneous  injections  of  morphia  and  atropine,  vomiting  and 
pains  were  relieved  ;  but  there  was  no  return  of  appetite,  much  flatu- 
lence and  obstinate  constipation  ;  and  patient  continued  to  lose  flesh 
and  strength.  On  April  1  a  nodule  about  size  of  pea  could  be  felt 
beneath  skin,  an  inch  above  umbilicus.  On  April  27  ascites  was  dis- 
covered; girth  at  umbilicus  was  32  in.,  and  on  May  6  this  had  in- 
creased to  35  in.  On  May  2  feet  were  noticed  to  be  swollen.  On 
May  16  bile-pigment  was  found  in  urine,  and  stools  were  white  ;  and 
on  May  20  there  was  decided  jaundice.  On  May  28  patient  became 
much  worse ;  he  was  so  weak  that  he  could  scarcely  turn  in  bed ; 
tongue  dry ;  paroxysms  of  dyspnoea  on  slight  exertion.  Towards 
evening  he  passed  into  a  state  of  stupor,  which  continued  until  death 
early  next  morning. 

Autopsy. — Eight  pints  of  clear  yellow  serum  in  peritoneum.  Liver 
of  about  normal  size,  but  studded  with  masses  of  soft  yellow  cancer  ; 
its  capsule  thickened  and  adherent.  The  tumour  felt  during  life  was 
situated  immediately  below  left  lobe  of  liver,  and  sprang  from  duode- 
num and  pyloric  end  of  stomach.  The  first  part  of  duodenum,  to 
length  of  5  in.,  had  its  coat  greatly  (f  in.  at  some  places)  thickened 
from  cancerous  deposit,  at  some  places  firm  and  translucent  and  at  others 
softer,  more  opaque  and  yellow.  This  morbid  deposit  extended  also 
four  or  five  inches  into  stomach,  but  beyond  pylorus  it  was  not  nearly 
so  thick.  Mucous  membrane  of  first  part  of  duodenum  and  of  pyloric 
end  of  stomach  extensively  ulcerated,  and  channel  through  duodenum 
narrowed.  On  outer  surface  of  duodenum  was  a  large  mass  of  cancerous 
excrescences.  Glands  in  fissure  of  liver  and  mesenteric  glands  enlarged 
from  cancerous  deposit,  and  lumbar  glands  also  enlarged  so  as  to 
form  a  tumour  pressing  peritoneum  forwards  and  eroding  upper 
lumbar  vertebrae ;  body  of  first  lumbar  vertebra  almost  eaten  through. 
Spleen  5;^  oz.  healthy.  Kidneys,  heart,  and  lungs  healthy.  Glands 
around  root  of  left  lung  enlarged  to  size  of  hen's  egg  from  cancerous 
deposit ;  ten  ounces  of  fluid  in  left  pleura. 

c  c  2 


388  JAUNDICE, 


Case  CXXIX. —  Cancer  of  Duodenum  stir  rounding  Hepatic  Duct-' 
Secondary  Cancer  of  Liver — Jaundice  and  Ascites — Death  from  Lobidar 
Pneumoiiia. 

Thomas  M ,  aged  36,  carman,  adm.  into  Middlesex  Hosp.  Jnly 

28,  1869.  Father  and  mother  alive  and  healthy  ;  no  history  of  malig- 
nant disease  in  family.  Never  had  syphilis,  and  excepting  contagious 
diseases  of  childhood  and  an  attack  of  variola,  had  good  health  up  to 
present  illness.  On  Dec.  24,  1868,  he  got  wet  through  and  his  clothes 
dried  on  him.  Three  days  afterwards  was  seized  with  cough  and  a 
dull  aching  pain  below  right  nipple.  After  three  days  pain  shifted  to 
epigastrium,  where  it  remained  nine  days,  but  was  never  very  severe, 
and  during  this  time  he  vomited  on  two  or  three  occasions.  On  pain 
ceasing,  which  it  did  rather  suddenly,  he  noticed  that  skin  and  eye- 
balls were  yellow.  Since  then  he  has  been  free  from  pain,  nausea,  or 
vomiting  ;  but  jaundice  has  persisted,  there  has  been  a  constant  feeling 
of  general  lassitude  with  moderate  diarrhoea,  and  he  has  continued  to 
lose  flesh.  Five  weeks  before  admission  his  feet  and  legs  began  to 
swell,  but  he  did  not  give  up  his  work  until  five  days  before  admission, 
when  he  was  attacked  with  cough  and  expectoration. 

On  admission,  patient  was  very  emaciated  and  deeply  jaundiced  ; 
considerable  anasarca  of  both  legs  and  decided  pitting  of  trunk.  Com- 
plained chiefly  of  great  weakness  and  of  diarrhoea ;  seven  or  eight 
motions  in  24  hours  ;  stools  liquid,  without  any  trace  of  bile-pigment, 
but  depositing  a  granular  slate-coloured  sediment,  containing  appa- 
rently altered  blood.  Tongue  clean,  red  and  dry  down  centre  ;  thirst ; 
no  vomiting.  Liver  enlarged ;  measures  in  r.  m.  1.  5  in.,  of  which  3 
in.  below  ribs  ;  surface  smooth,  and  not  tender  ;  lower  margin  firm  and 
sharp.  Slight  ascites  ;  no  enlargement  of  abdominal  veins  or  of  spleen  ; 
no  haemorrhoids.  Pulse  92,  rather  feeble ;  signs  of  heart  noi'mal. 
Frequent  cough  with  expectoration  of  tenacious  bronchial  mucus  ;  resp. 
24;  sonorous  and  sibilant  rales  with  prolonged  expiration  over  front 
of  both  lungs  and  a  few  moist  sounds  at  back  ;  no  dulness.  Temp. 
101 '4°.  No  itchiness  of  skin.  Urine  1010  ;  contains  much  bile-pig- 
ment, but  no  albumen. 

Patient  was  ordered  milk,  eggs,  3  oz.  of  brandy,  a  mixture  of 
bismuth,  chloric  ether,  and  a  few  drops  of  laudanum  and  sinapisms 
to  chest.  For  first  two  or  three  days  he  felt  much  better,  tongue 
became  moist,  and  diarrhoea  abated.  The  fever,  however,  persisted, 
pulse  ranging  from  88  to  120  and  temperature  from  101"4°to  104°.  On 
night  of  August  1  he  became  much  Avorse ;  respirations  rose  to  44 ; 
and  on  Aug.  2  he  was  very  low  and  prostrate ;  scarcely  conscious,  dry 
tongue  and  involuntary  evacuations.  These  symptoms  continued 
until  death  in  evening  of  Aug.  3. 

Autopsy. — Much  sero-sanguineous  infiltration  of  both  lungs ;  and 


LECT.  X.  FEOM    OBSTEUCTION    OF    BILE-DUCT.  3  89 

in  lower  lobes  of  both,  organs  (most  in  right)  were  many  small  scattei'ed 
nodnles  of  recent  lobular  pneumonia.  Stomach  healthy.  Orifice  of 
bile-duct  surrouiided  by  a  mass  of  encephaloid  cancer  projecting  into 
duodenum.  A  similar,  but  much  smaller,  growth  projected  from 
mucous  surface  a  few  lines  further  down.  The  larger  growth,  on  dis- 
section, was  found  to  be  about  size  of  a  walnut.  Beyond  it  common 
and  hepatic  ducts  were  greatly  dilated,  former  measuring  1^  in.  in 
circumference.  Liver  large,  weighing  74^  oz.,  and  containing  several 
small,  isolated,  and  at  some  parts  confluent,  nodules  of  morbid  deposit, 
composed  of  a  fibrous  stroma  enclosing  in  its  meshes  large  ovate  and 
caudate  cells.  Spleen  11  oz. ;  healthy.  All  other  abdominal  organs 
healthy. 

TKe  jaundice  in  the  next  case  was  also  the  result  of  cancer, 
the  primary  seat  of  which  appeared  to  be  in  the  areolar  tissue 
and  glands  surrounding  the  head  of  the  pancreas.  But  the 
immediate  cause  of  the  jaundice  was  an  independent  pendulous 
cancerous  tumour  growing  in  the  interior  of  the  bile-duct. 
Similar  tumours  were  found  in  the  portal  vein  and  in  the  duo- 
denum. 

Case  CXXX. — Cancerous   Tumours  of  Duodenum,  and   in   interior  of 
Bile-ducts  and  Portal  Vein — Jaundice — Ascites. 

Elizabeth  M -,  aged  50,  adm.  into  St.  Thomas's  Hosp.  Ap.  17, 

1872.  Her  mother  had  a  tumour  in  neck  for  30  years,  which  nine 
months  before  death  was  said  to  '  turn  into  cancer,'  and  she  died  of 
the  effects  of  it.  Three  years  before  admission  patient  noticed  a  lump 
about  size  of  a  hen's  eg^  in  right  hypochondrium.  Eight  months  ago 
this  began  to  increase  slowly,  but  it  was  never  the  seat  of  pain,  except 
when  pressed  on  ;  and  her  general  health  did  not  suffer  until  three 
months  ago,  when  she  began  to  lose  flesh.  Eight  weeks  ago  she  began 
to  vomit  food  once  or  twice  daily  an  hour  or  two  after  meals.  Three 
weaks  ago  jaundice  appeared  ;  it  was  preceded  for  a  week  by  diarrhoea, 
but  by  no  pain  nor  increase  of  retching. 

On  admission  patient  was  emaciated  and  deeply  jaundiced,  but 
countenance  not  expressive  of  pain.  She  complained  of  occasional 
attacks  of  severe  pain  in  abdomen,  lasting  sometimes  three  hours  and 
keeping  her  awake  at  night.  A  large  prominence  in  centre  of  ab- 
domen, mainly  below  umbilicus  and  due  to  a  ventral  hernia ;  but  its 
upper  part  formed  by  a  hard  mass  lying  between  umbilicus  and  right 
ribs,  nodulated,  sometimes  tender,  extending  deeply  backwards  into 
abdomen,  but  at  same  time  slightly  movable  and  with  a  clear  per- 
cussion space  between  it  and  liver.  Hepatic  dulness  not  increased. 
Tongue  slightly  coated  ;  appetite  fair,  but  uneasiness  after  food,  which 
was  often  vomited  about  two  hours  after  ingestion ;  bowels  regular ; 


390  JAUNDICE,  lECT.  X. 

no  bile  in  stools.  No  ascites.  Urine  deeply  coloured  with  bile-pig- 
ment.    Pulse  72.     Heart  and  other  organs  healthy. 

Patient  was  ordered  a  pill  with  creasote  and  morphia  twice  daily, 
and  subsequently  bismuth,  and  milk  diet.  At  first  there  was  a  great 
improvement ;  but  on  May  13  appetite  began  to  fail ;  and  on  May  16 
pain  was  so  severe  that  it  was  necessary  to  inject  moiiDhia  subcu- 
taneously,  and  there  was  some  evidence  of  ascites,  which  rapidly  in- 
creased. On  May  19  slight  diarrhoea  set  in,  and  motions  were  found 
to  contain  a  large  quantity  of  solidified  fatty  matter.  From  time  that 
diarrhoea  set  in  vomiting  ceased  for  ten  days.  On  June  4,  abdomen 
was  greatly  distended  with  fluid,  its  walls  being  very  tense  and  glisten- 
ing, and  patient  complained  much  of  tightness  and  dyspnoea.  Legs 
also  were  becoming  oedematous.  Occasional  vomiting  of  mucus 
streaked  with  blood.  Sixteen  pints  of  clear  fluid  were  drawn  ofi"  by 
paracentesis,  after  which  patient  was  greatly  relieved,  but  she  con- 
tinued to  sink,  and  died  on  June  7. 

Aiitopsy. — Nearly  a  gallon  of  deep  yellow  turbid  serum  in  peritoneum. 
Behind  duodenum  was  a  \axge  lobulated  tumour  composed  mainly  of 
enlarged  lymphatic  glands  surrounding  head  of  pancreas.  Duodenum 
was  found  to  contain  a  vascular  pendulous  mass  of  cancer,  about  2  in. 
long  and  1  in.  broad,  which  broke  off  on  opening  bowel,  but  had  been 
attached  by  a  jDcdicle  as  large  as  a  quill  to  interior  of  a  sinus-like  pouch 
1  in.  in  length,  close  to,  but  distinct  from  bile-duct.  Near  to  this  were 
several  other  sinuses  containing  cylindrical  masses  of  new  growth. 
On  cutting  into  tumour  it  was  found  to  be  traversed  by  sinuses  con- 
taining similar  masses  of  new  growth.  Similar  new  growths  were 
found  in  interior  of  splenic  and  portal  veins,  as  well  as  of  branches 
of  latter  inside  liver.  Another  was  found  inside  hepatic  duct  at  its 
junction  with  cystic.  Beyond  this,  hepatic  dnct  very  greatly  dilated, 
admitting  two  fingers  ;  bile-ducts  throughout  liver  also  greatly  dilated  ; 
gall-bladder  greatly  distended.  Pancreatic  duct  could  not  be  found. 
A  small  vascular  growth  was  growing  from  peritoneal  surface  of  fundus 
uteri.     Spleen,  kidneys,  and  other  organs  normal. 

In  Case  CXXXI.  the  jaundice  was  caused  by  primary 
ca.ncer  of  the  glands  in  the  portal  fissure,  wliicli  obliterated  the 
hepatic  duct  but  sjDared  the  common  duct  and  the  portal  vein. 
Here  also  the  patient  at  first  improved  and  gained  weight 
under  treatment. 

Case  CXXXI. — Scin-hus  of  Glands  in  Portal  Fissttre  ohllterating  Hepatic 
Duct  and  causing  Jaundice — Common  Duct  and  Portal  Vein  free. 

William  R ,  aged  G3,  mattress- maker,  adm.  into  St.   Thomas's 

Hosp.  April  7,  187r).  An  only  child;  father  died  young  of  scai-latina  ; 
mother  died  at   75.     Twenty-four  years   ago,  ill   for  six  weeks  with 


i,ECT.  X.  FROM    OBSTRUCTION    OF    BILE-DUCT.  39 1 

'  inflammation  of  lungs  and  liver,'  and  seven  years  ago  again  ill  for  six 
weeks  with  pain  in  back  and  diarrhoea.  With  these  exceptions  had 
enjoyed  good  health  ;  never  had  gout  or  syphilis,  and  digestion  had 
been  good.  Ten  weeks  ago  began  to  lose  appetite  and  to  sufier  from 
nausea,  retching,  and  pains  in  back,  shoulders,  and  stomach.  After 
two  weeks  jaundice  appeared,  and  at  end  of  another  week  he  was 
obliged  to  give  ujd  work.  From  first  he  had  rapidly  lost  flesh  and 
strength. 

On  admission,  emaciation,  deep  jaundice  ;  great  itchiness,  keeping 
him  awake.  Stools  devoid  of  bile-pigment  and  urine  loaded  with  it. 
Tongue  white  :  appetite  better  than  it  had  been ;  no  vomiting  for  five 
days ;  bowels  regular.  No  ascites  ;  no  enlargement  of  abdominal 
veins  ;  and  no  induration  around  navel.  Liver  enlarged,  measuring  6 
in.  in  r.  m.  1. ;  surface  smooth.  ISTo  pain  in  liver  ;  no  oedema  of  legs  ; 
no  albuminuria.     Pulse  45  to  60 ;  heart  normal.     Temp.  97°. 

During  first  three  weeks  was  treated  with  citrate  of  potash  in 
efiervescence,  and  improved  considerably,  gaining  2  lbs.  in  weight  ; 
but  on  two  or  three  occasions  he  had  an  attack  of  rather  severe 
pain  across  upper  part  of  abdomen,  lasting  about  an  hour.  On 
April  28  he  had  an  unusually  severe  attack  of  pain  with  a  return  of 
vomiting ;  and  after  this  appetite  again  failed ;  vomiting  and  pain 
recurred  frequently ;  and  there  was  a  daily  loss  of  flesh  and  strength. 
On  June  11  he  began  to  vomit  black  blood,  and  to  pass  a  considerable 
quantity  in  clots  per  anum.  After  this  he  became  rapidly  weakei",  and 
on  June  20  he  died. 

Autopsy. — No  fluid  in  peritoneum.  Pancreas  and  duodenum 
adherent  to  under  surface  of  liver ;  but  both  healthy.  In  portal 
fissure  was  a  nodule  of  new  growth,  size  of  small  orange,  of  firm 
consistence,  adherent  to  surrounding  organs  by  fibrotis  bands,  and 
penetrating  substance  of  liver  for  about  an  inch.  This  growth  sur- 
rounded, infiltrated,  and  completely  obstructed  hepatic  duct  for  about 
half  an  inch.  Above  this  all  branches  of  duct  were  greatly  dilated, 
and  filled  with  thin  bile.  Greater  part  of  right  lobe  of  liver  was  con- 
verted into  a  cavernous  structure  formed  by  the  dilated  ducts,  with 
atrophy  and  induration  of  intervening  tissues  ;  some  of  these  dilated 
ducts  pi'ojected  like  cysts,  size  of  peas,  from  surface.  Gall-bladder 
contained  about  three  drachms  of  bile  ;  a  probe  passed  readily  from  it 
through  cystic  and  common  bile-duct  into  duodenum,  and  these  ducts 
were  of  normal  size.  Wall  of  portal  vein  opposite  point  of  obstruction 
of  hepatic  duct  was  infiltrated  to  -^^  in.  in  thickness  for  about  a  third 
of  an  inch,  but  its  lumen  was  not  obstructed.  On  microscopic  exami- 
nation, new  growth  was  found  to  have  structure  of  scirrhus.  A  few 
other  of  the  lymphatic  glands  in  the  portal  fissure  were  enlarged  and 
contained  new  growth  ;  but  there  was  no  other  deposit  either  in  liver 
or  in  any  other  organ.  Stomach,  intestines,  spleen,  kidneys,  and 
heart  healthy,     ffidema  and  hyjDostatic  congestion  of  both  lungs. 


392  JAUXDICE,  LECT.  X. 

In  Case  CXXXII.  jaundice  resulted  from  the  obstruction 
of  the  common  bile-duct  b}'  a  scirrhous  mass  originating 
in  the  post-peritoneal  glands.  The  mode  of  commencement 
was  unlike  gall-stones  or  catarrh  of  the  ducts  ;  and  primary 
cancer  of  the  liver,  wliich  at  first  suggested  itself,  was  negatived 
by  the  shrinking  which  followed  the  original  enlargement  of 
the  liver.  The  most  probable  diagnosis  seemed  to  be  cancer  of 
the  head  of  the  pancreas,  but  the  post-mortem  examination 
showed  that  the  disease  had  originated  in  the  post-peritoneal 
glands,  and  in  connection  with  this  it  is  interesting  to  observe 
that  the  prominent  symptom  throughout  was  pain  in  the 
back. 

Case  CXXXII. — Cancer  of  Fost-perUoneal  Glands  ohstrudivg  Bile-duct 
and  Portal  Vein — Secondary  Deposits  in  Liver  and  Lungs. 

Ellen  F ,  aged  60,  adm.  into  St.  Thomas's  Hosp.  May  18,  1875. 

Father  died  at  57  of  typhus  ;  and  mother  at  60  ;  two  brothers  and  one 
sister  died  young  of  vai'iola.  Married  at  17;  12  childi-en ;  habits 
temperate.  Ten  years  ago  had  low  fever ;  and  two  years  ago  some 
slight  hepatic  derangement ;  but  with  these  exceptions  health  good 
till  about  six  months  ago.  when  she  began  to  lose  flesh  and  strength, 
and  to  suffer  from  loss  of  appetite,  flatulence,  and  transient  attacks  of 
pain  in  back.  After  two  months  pains  in  back  recurred  more  fre- 
quently ;  two  months  later  nausea  and  itchiness  of  skin  set  in ;  one 
month  before  admission  she  began  to  be  jaundiced.  After  jaundice 
appeared,  pain  in  back  became  more  constant  and  severe ;  ten  days 
before  admission  she  had  for  first  time  a  sharp  pain  in  liver  lasting 
about  a  minute,  and  four  days  before  admission  she  vomited  once. 

On  admission,  emaciated  and  very  deeply  jaundiced,  with  much 
itchiness  of  skin.  Still  much  pain  across  back,  but  none  in  liver, 
which  is  much  enlarged.  Upper  margin  not  too  high,  but  lower 
margin  fully  3^  in.  below  ribs  in  r.  m.  1.,  vertical  dulness  here 
measuring  G  in.  ;  surface  smooth,  firm,  not  tender;  no  induration 
about  umbilicus;  no  ascites;  no  oedema  of  legs  nor  enlargement  of 
spleen.  Tongue  coated ;  breath  offensive ;  appetite  middling ;  no 
retching ;  much  flatulence,  but  no  severe  pain  after  food  ;  bowels 
i-cgular ;  stools  clay-coloured,  and  sometimes  contain  blood  after 
straining.  Urine  loaded  with  bile-pigment ;  no  albumen.  Pulse  7-  ; 
heart-  and  lung-signs  normal. 

Patient  was  treated  with  mineral  acids,  nux  vomica,  and  ginger, 
with  occasional  aperients.  She  had  fish  or  meat  and  a  small  quantity 
of  wine.  She  impi-oved  at  first,  but  then  gradually  got  worse.  Pain 
in  back  was  very  constant  and  was  relieved  by  morphia ;  but  no 
return  of  hepatic  pain.     On  May  21,  June  27,  and  July  22,  she  vomited 


LECT.  X.  FEOM    OBSTEUCTION    OF    BILE-DUCT.  393 

food.  At  first  bowels  were  costive,  but  on  June  20  she  bad  an  attack 
of  diarrhoea  which  lasted  several  days,  five  or  six  motions  a  day,  and 
after  this  motions  usually  dark,  as  if  from  blood.  Emaciation  in- 
creased ;  jaundice  persisted ;  liver  gradually  diminished  in  size ;  and 
on  July  24  ascites  was  discovered,  which  rapidly  increased.  She  was 
still  able  to  eat  and  retain  meat ;  but  on  Aug.  7  she  became  very 
prostrate  and  mind  wandered,  and  on  Aug.  9  she  died. 

Autopsy. — Peritoneum  contained  a  large  quantity  of  clear  bile- 
stained  fluid.  Behind  head  of  pancreas  and  projecting  slightly  above 
it  was  a  dense  nodulated  mass,  about  size  of  small  orange,  firmly 
adherent  to  surrounding  parts,  and  enclosing  bile-duct  and  portal  vein. 
On  section  this  was  found  to  have  originated  in  glands  behind  pancreas, 
and  to  consist  of  dense  cicatricial  tissue.  Superior  mesenteric 
artery  passed  through  it  near  its  centre ;  it  was  compressed  and  nar- 
rowed, but  its  coats  were  free  from  infiltration.  Common  bile-duct 
passed  into  it  at  its  upper  part,  about  half  an  inch  from  junction  of 
cystic  and  hepatic  ducts,  and  became  completely  obliterated.  Portal 
vein  was  also  narrowed  and  its  walls  much  thickened  and  infiltrated 
for  about  three  quarters  of  an  inch,  and  opposite  point  of  entry  into 
mass  was  an  adherent  discoloured  thrombus,  extending  upwards  for 
about  an  inch,  but  not  completely  obstructing  vessel.  Gall-bladder 
distended  with  a  clear  colourless  viscid  fluid  and  about  sixty  small 
calculi,  size  of  peas ;  its  fundus  was  about  |  in.  thick  from  presence  of 
new  growth,  of  which  there  were  also  several  rounded  nodules  in 
adjacent  substance  of  liver.  Liver  atrophied  and  dense ;  large 
patches  of  fibrous  thickening  of  capsule  ;  branches  of  hepatic  duct 
greatly  dilated  and  full  of  colourless  fluid.  Catarrhal  inflammation 
and  hsemorrhagic  erosions  of  stomach.  Spleen,  kidneys,  and  heart 
healthy.  Lower  lobes  of  both  lungs  studded  with  numerous  nodules 
of  new  growth  similar  to  those  in  liver,  from  size  of  a  mustard-seed  to 
that  of  a  large  pea. 


394  JAUNDICE, 


LECTURE   XI. 
JAUNDICE. 

JAUNDICE    INDEPENDENT    OF    OBSTRUCTION    OF    THE    BILE-DUCT;    DIAGNOSIS    OF    THE 
CAUSES    OF    JAUNDICE. 

Gentlemen, — In  my  last  lecture  I  explained  to  you  that 
jaundice  in  those  cases  where  it  is  independent  of  any  me- 
chanical impediment  to  the  escape  of  bile  from  the  liver  might 
be  referred  to  one  of  the  following  causes,  viz. — 

I.  Poisons  in  the  blood  interfering  with  the  normal  meta- 
morphosis of  bile. 

II.  Impaired  or  deranged  innervation  interfering  with  the 
normal  metamorphosis  of  bile,  or  increasing  its  secretion. 

III.  Deficient  oxygenation  of  the  blood  interfering  with 
the  normal  metamorphosis  of  bile. 

IV.  Excessive  secretion  of  bile,  so  that  more  is  absorbed 
than  can  undergo  the  normal  metamorphosis. 

V.  Undue  retention  of  bile  in  the  biliary  passages  and 
bowels,  from  habitual  or  protracted  constipation. 

I  purpose  devoting  the  greater  part  of  this  lecture  to  the 
consideration  of  jaundice  from  these  various  causes. 

I.    JAUNDICE    FEOM    POISONS    IN    THE    BLOOD. 

Cases  are  not  uncommon  in  which  jaundice  results  from  a 
poisoned  or  morbid  condition  of  the  blood,  such  as  that  which 
exists  in  persons  affected  with  the  various  sj)ecific  fevers.  It 
is  very  probable  that  when  jaundice  occurs  in  such  cases,  its 
mechanism  is  not  always  precisely  the  same.  Sometimes,  as 
for  instance  in  many  cases  of  ague  and  relapsing  fever,  it  is 
associated  with  considerable  enlargement  and  congestion  of 
the  liver,  and  this  congestion  is  often  the  chief,  if  not  the  sole, 
cause  of  the  jaundice  ;  and  at  other  times  the  duodenal  orifice 
of  the  duct  ma}'  be  plugged  by  catarrhal  inflammation.  But 
in   many,  and   these   are   much  the  more  serious  cases,  the 


i,ECT.  XI.  WITHOUT    OBSTRUCTION    OF    BILE-DUCT.  395 

jaundice  is  independent  of  either  congestion  of  the  liver,  or  of 
obstruction  of  the  bile-duct :  during  life  there  is  no  lack  of 
bile  in  the  evacuations,  and  after  death  the  liver  is  often  anaemic 
rather  than  congested.  In  these  cases  too,  the  cerebral  and 
other  phenomena  of  the  typhoid  state  are  usually  prominently 
developed,  and  there  is  reason  to  believe  that  here,  as  in  other 
diseases,  this  typhoid  condition  is  due,  not  to  the  presence  of 
bile  in  the  blood  (see  p.  322),  but  to  imperfect  elaboration  or 
elimination  of  the  normal  products  of  metamorphosis  of  the 
blood  and  tissues,  of  which  the  jaundice  is  only  a  visible  sign. 
Although  careful  observations  on  this  form  of  jaundice  are  still 
wanting,  it  has  been  repeately  noticed  that  there  is  a  diminu- 
tion of  urea  in  the  urine,  and  that  in  some  instances  the  urine 
has  been  found  to  contain  leucin  and  tyrosin,  which,  as  I  have 
already  told  you,  are  indications  of  imperfect  metamorphosis  . 
(see  pp.  263,  324).  The  general  condition  of  the  patient,  in 
fact,  is  very  similar  to  what  has  been  described  to  you  in  a 
previous  lecture  as  occurring  in  acute  or  yellow  atrophy  of  the 
liver  (see  p.  262),  and  it  is  very  probable  that  the  pathology 
of  the  two  conditions  is  similar.  In  both  there  is  a  morbid 
condition  of  the  blood,  as  the  result  of  which  the  metamor- 
phoses which  usually  go  on  in  that  fluid  are  impeded  or  arrested ; 
and  there  is  a  deficient  excretion  of  urea  and  a  tendency  to  the 
development  of  leucin  and  tyrosin  in  the  liver,  spleen,  kidneys, 
blood,  and  urine.  In  both,  the  jaundice  is  probably  merely 
one  of  the  results  of  this  impaired  metamorphosis,  the  bile- 
]3igment  absorbed  into  the  blood  not  being  transformed  as  in 
health.  Occasionally  the  liver  presents  an  appearance  like 
that  of  an  early  stage  of  acute  atrophy,  and  indeed  I  have 
already  had  occasion  to  tell  you,  that  the  poisons  of  typhus 
fever  and  of  other  allied  diseases  must  be  reckoned  among  the 
causes  of  yellow  atrophy  of  the  liver  (p.  266). 

We  may  now  consider  very  briefly  jaundice  as  it  results 
from  the  several  blood-poisons,  some  of  which  give  rise  to  it 
much  more  readily  than  others. 

1.   The  Poisons  of  the  various  Bpecific  Fevers. 

a.  Yellow  Fever. 

The  yellow  fever  of  the  tropics  derives  its  name  from  the 
frequency  with  which  it  is  complicated  with  jaundice.  It  has 
been  demonstrated  over  and  over  again  that  the  yellow  sufiii- 


396  JAUNDICE,  LECT.  XI. 

sion  of  tlie  skiu  and  eyes  in  tliis  disease  is  occasioned  by  the 
presence  of  bile,  which  is  also  found  in  the  urine.     Post-mortem 
examinations  and  the  fact  that  in    the  earlier  stages  of  the 
disease  there  is  a  full  supply  of  bile  in  the  alvine  evacuations 
have  satisfiictorily  proved  that  the  jaundice  is  independent  of 
any  impediment  to  the  escape  of  bile  from  the  liver.     On  the 
other  hand,  as  in  acute  atrophy  of  the  liver,  the  jaundice   is 
usually  associated  with  hsemorrhages,  'black  vomit,'  delirium, 
and  the  other  symptoms  of  the  typhoid  state.     There  are  good 
reasons  also  for  believing  that  this  typhoid  condition  is  due  to 
the  same  cause  as  in  acute  atrophy,  viz.,  impaired  or  deranged 
metamorphosis  in  the  blood  and  tissues,  and  retention  in  the 
system  of  those  products  of  metamorphosis  which  ought  to  be 
eliminated  by  the  kidneys.     The  urine  in  most  cases  is  albu- 
minous and  contains  tube-casts,  and  is  occasionally  suppressed. 
E-oche  has  found  a  deficiency  of  urea  in  the  urine,  but  a  large 
quantity  of  it  in  the  blood  ;  ^  Blair  has  detected  a  large  amount 
of  carbonate  of  ammonia  in  the  blood,  and  also  in  the  expired 
air ;  ^  while  Lallemant  describes  the  sweat  as  of  a  penetrating 
urinous  odour.'^     The  liver  at  first  is  enlarged  from  hyperemia, 
but  in  the  advanced  stage  of  the  disease  it  is  pale  and  reduced 
in  size,  and  the  secreting  cells  are  often  loaded  with  oil."*     The 
kidneys  are  also  usually  found  to  be  large  and  congested  in  the 
early  stage,  but  later  in  the  disease  the  cortex  is  hypertrophied 
and  the  secreting  tubes  gorged  with  granular  epithelium.    From 
what  has  been  stated  it  seems  but  fair  to  conclude,  that  the 
jaundice  of  yellow  fever  is  only  one  of  the  results  of  that  im- 
pairment or  derangement  of  the  metamorphoses  taking  place 
in  the  blood  and  tissues,  of  the  existence  of  which  there  is 
such  abundant  proof. 

h.  Malarious  Remittent  and  Intermittent  Fevers. 
The  occurrence  of  jaundice  in  the  malarious  remittent  and 
intermittent  fevers  of  India,  Algeria,  and  of  other  countries 

'  Yellow  Fever,  Philadelphia,  1855. 

*  Keport  on  Yellow  Fever,  by  Daniel  Blair,  M.D.,  pp.  39,  40.  Brit,  and  For. 
Med.-Chir,  Rev.,  April  1856. 

'  Frerichs,  op.  cit.  i.  p.  183. 

*  Of  thirteen  fatal  cases  dissected  by  Louis  at  Gibraltar  the  consistence  of  the 
liver  was  diminished  in  seven.  'Its  colour  was  altered  in  every  case;  sometimes  it 
was  of  the  colour  of  fresh  butter,  sometimes  of  a  straw  yellow,  or  of  a  clear  coffee  and 
milk  colour,  sometimes  of  a  gum  yellow,  sometimes  of  an  orange  yellow.'  Graves, 
Clin.  Lect.,  2nd  ed.  i.  p.  283. 


LECT.  XI.  WITHOUT    OBSTEUCTION    OF    BILE-DUCT.  397 

where  true  yellow  fever  is  believed  to  be  unknown,  lias  been 
repeatedly  noted.  Twenty-four  years  ago  I  met  witb  it  in  the 
malarious  fevers  of  Burmah  ;  '  and  Morehead,  one  of  the  latest 
and  best  writers  on  Indian  diseases,  observed  jaundice  in 
twenty-eight  out  of  one  hundred  and  fourteen  cases  of  remittent 
fever.^  In  Algeria  jaundice  has  been  sometimes  noted  in  as 
many  as  seven-tenths  of  the  cases  of  intermittent  fever.^  The 
jaundice  in  these  cases  a;rises  in  different  ways.  Sometimes  it 
is  associated  with  congestive  enlargement  of  the  liver,  or  with 
gastro-duodenal  catarrh^  more  or  less  obstructing  the  flow  of 
bile  and  causing  deficiency  of  bile  in  the  motions ;  in  both 
these  cases  the  general  symptoms  are  often  mild.  But  in 
other  cases  which  are  usually  fatal,  jaundice  is  found  associated 
with  a  dry,  brown  tongue,  drowsiness,  delirium,  tremors, 
subsultus,  and  other  symptoms  of  the  typhoid  state,  with 
petechise  and  haemorrhages  from  the  stomach  and  bowels,  and 
with  albuminous  and  bloody  urine,  which  is  sometimes  com- 
pletely suppressed.^  Careful  analyses  of  the  blood  and  urine 
in  these  cases  have  still  to  be  made,  but  there  can  be  little 
doubt  that  the  general  condition  is  similar  to,  if  not  identical 
with,  that  of  the  typhoid  state  in  yellow  fever,  in  British 
typhus,  and,  in  fact,  in  acute  diseases  generally.^  In  these 
severe  cases  of  remittent  fever  the  bile-ducts  have  been  found 
by  Morehead  and  other  observers  perfectly  patent  and  free 
from  catarrhal  inflammation,  while  the  liver  has  been  noted  to 
be  but  slightly  congested,  and  sometimes  pale  and  in  a  state 
of  fatty  degeneration.  The  jaundice  in  these  cases  appears  to 
result  from  a  condition  of  the  blood  unfavourable  to  the  meta- 
morphosis of  the  absorbed  bile. 

'  Notes  on  the  Climate  and  Diseases  of  Burmah,  Ed.  Med.  and  Surg.  Journ. 
April  1855,  p.  229. 

^  Clinical  Researches  on  Disease  in  India,  2nd  ed.  1860,  p.  73. 

^  Eoudin,  Traite  des  fievres  intermit.     Paris,  1842. 

^  Frerichs,  op.  cit.,  vol.  i.  p.  180 

*  In  1853  I  found  no  albumen  in  the  urine  of  persons  suffering  from  remittent 
fever  in  Burmah.  My  observations,  vt'liich,  for  the  most  part,  were  made  early  in  the 
disease  before  the  supervention  of  typhoid  symptoms,  have  been  quoted  as  establish- 
ing a  distinction  between  malarious  remittents  and  true  yellow  fever.  The  compa- 
rative frequency,  however,  of  albuminuria  in  yellow  fever  is  probably  due  to  the  fact 
that  the  typ)hoid  state  is  much  more  common  in  this  disease  than  in  malarious 
remittents.  When  the  typhoid  state  is  developed  in  remittent  fever,  it  would  indeed 
be  extraordinary  if  it  differed  from  the  typhoid  state  of  all  other  diseases  in  the 
absence  of  albuminuria.  Moreover,  in  intermittents  depending  on  the  same  malaria 
as  remittent  fevers,  albumen  and  even  blood  are  not  uncommon  in  the  urine. 


398  JAUXDICE,  LECT.  XI. 

c.  Relapsing  Fever, 

Jaundice  has  been  a  frequent  symptom  in  the  relapsing 
fever  of  Great  Britain  and  Ireland.  Indeed,  the  frequency 
with  which  relapsing  fever  has  been  complicated  with  jaun- 
dice, and  even  with  black  vomit,  has  often  caused  it  to  be  mis- 
taken for  true  yellow  fever  In  1826  Drs.  Graves  and  Stokes 
published  an  account  of  the  '  yellow  fever '  of  Dublin,  and 
the  twenty-first  chapter  of  the  first  volume  of  Graves'  unrivalled 
Clinical  Lectures  is  entitled  '  Yellow  Fever  of  the  British 
Islands.'  It  is  now  generally  admitted,  that  the  cases  described 
by  these  writers  were  instances  of  relapsing  or  famine  fever 
complicated  with  jaundice  and  cerebral  symptoms,  and  their 
distinctness  from  true  yellow  fever  was  pointed  out  at  the  time 
by  O'Brien.^  The  Scotch  epidemic  of  1843  was  likewise  re- 
garded as  closely  allied  to,  if  not  identical  with,  yellow  fever 
by  many  of  its  most  distinguished  observers,  and  it  was  even 
fancied  that  the  disease  had  been  imported  into  Glasgow  by 
merchant-vessels  from  the  West  Indies,  although  in  truth  it 
had  been  prevailing  in  the  east  of  Scotland  for  some  time 
before  it  appeared  in  Glasgow.^  There  is,  it  is  true,  a  strong 
resemblance  between  the  more  severe  forms  of  relapsing  fever 
complicated  with  jaundice  and  typhoid  symptoms,  and  tropical 
yellow  fever,  but  we  have  here  another  illustration  of  the  mis- 
takes which,  I  have  told  you,  are  apt  to  result  from  founding 
analogies  or  differences  between  acute  specific  diseases  on 
symptoms  alone,  and  of  neglecting  the  circumstances  under 
which  they  appear,  or,  in  other  words,  their  causes. 

The  frequency  of  jaundice  in  relapsing  fever  has  been 
variously  estimated,  but  on  an  average  it  may  be  said  to  have 
been  noticed  in  one  out  of  every  five  cases.  The  jaundice  is 
independent  of  obstruction  to  the  escape  of  bile  from  the 
liver.  In  many  cases  the  associated  symptoms  are  mild  and 
the  patients  recover,  and  then  the  jaundice  is  probably  the 
result  of  the  congested  condition  of  the  liver  which  is  so  com- 
mon in  relapsing  fever.  Yet  most  observers  of  relapsing  fever 
have  agreed  in  making  jaundice  a  formidable  symptom,  and  it 
has  certainly  been  often  accompanied  by  ha}morrhages,  includ- 
ing black  vomit,  a  dry  brown  tongue,  delirium,  coma,  subsultus, 

'  Trans.  Queen's  Coll.  of  Tliys.  of  Dul.Jin,  1S2S,  p.  532. 

*  Murcliison  on   the  Conliuued  Fevers  of  Great  Britain,  2nd  ed.    1873,  pp.  47, 
395. 


LECT.  XI.  WITHOUT    OBSTEUCTION    OP    BILE-DUCT.  399 

convulsions,  and  other  cerebral  symptoms ;  and  at  the  same 
time  it  has  not  necessarily  been  associated  with  hepa,tic  con- 
gestion, but  often  with  a  soft,  pale,  and  yellow  condition  of 
the  liver  and  with  the  presence  of  leucin  and  tyrosin.'  As  in 
true  yellow  fever,  however,  these  serious  symptoms  are  not  due 
to  the  presence  of  bile  in  the  blood ;  but  the  jaundice  is  only  an 
outward  and  visible  sign  of  important  changes  in  the  blood 
interfering  with  the  natural  metamorphoses.  The  urine  has 
been  ascertained  to  be  suppressed  or  diminished  in  quantity 
and  very  deficient  in  urea,  which  has  been  found  in  abundance 
in  the  blood  and  in  the  cerebral  fluid.^ 

d.   Typhus  Fever. 

Yery  opposite  statements  have  been  made  as  to  the  occur- 
rence of  jaundice  in  true  typhus  fever.  Sir  W.  Jenner  states 
that  he  has  never  met  with  it,  whereas,  according  to  Frerichs, 
several  epidemics  of  petechial  typhus  have  been  characterised 
by  the  frequency  of  jaundice.  It  is  probable  that  Frerichs  has 
been  misled  by  the  frequency  with  which  epidemics  of  typhus 
and  relapsing  fevers  have  prevailed  together,  and  by  the  fact 
that  in  most  instances  the  latter  disease  has  been  regarded  as 
a  mere  variety  of  the  former.  At  all  events,  in  this  country 
and  in  Ireland  jaundice  is  a  very  rare  complication  of  true 
typhus.  In  1843  Dr.  Henderson  referred  to  the  occurrence  of 
jaundice  in  typhus  fever  ;  ^  two  cases  are  recorded  by  Frerichs ;  ^ 
fifteen  observed  by  myself  are  referred  to  in  my  work  on  the 
Continued  Fevers  of  Great  Britain  ;  and  Dr.  Hudson  of  Dublin 
also  speaks  of  jaundice  as  '  a  very  rare  complication  in  typhus.'  ^ 
The  rarity  of  jaundice  in  typhus,  as  well  as  the  severity  of  the 
cases  in  which  it  occurs,  may  be  judged  of  from  what  has  been 
observed  at  the  London  Fever  Hospital.  Out  of  7,604  cases  of 
true  typhus  admitted  into  the  hospital  during  the  years  1862,  3, 

'  In  two  fatal  cases"  of  relapsing  fever  witli  jaundice,  haemorrhage,  and  typhoid 
symptoms,  recorded  by  Sir  J.  Kose  Cormack,  the  liver  was  found  in  one  '  of  the 
natural  colour  and  consistence,' and  in  the  other  it  was  'softer  than  natural,' and 
'the  section  exhibited  a  dingy  lightish  colour.'  Nat.  Hist.,  Path.,  and  Treatment  of 
the  Epidemic  Fever  at  present  prevailing  in  Edinburgh  &c.,  1843,  Cases  VII.  and 
VIII.  In  the  epidemic  of  relapsing  fever  which  occurred  in  St.  Petersburg  in  1864, 
the  liver  was  repeatedly  found  in  a  state  of  acute  atrophy,  and  in  two  cases  of  this 
sort  Zuelzer  detected  in  the  organ  crystals  of  leucin  and  tyrosin. 

^  See  the  evidence  on  this  matter  collected  in  my  work  on  Fevers,  2nd  ed.  p.  367. 

»  Edin.  Med.  and  Surg.  Journ.  1844,  vol.  Ixi.  p.  220. 

*  Op.  cit.  i.  pp.  168,  170. 

*  Lectures  on  the  Study  of  Fever,  1867,  p.  88. 


400  JAUNDICE,  LBCT.  XI. 

4,  and  5,  jaundice  was  noted  in  only  16,  or  once  in  everj  475 
cases.     Of  the  16  cases,  12  were  fatal,  and  deducting  2  cases 
where  the  jaundice  did  not  occur  until  convalescence  and  was 
evidently  catarrhal,  of  the  remaining    14  patients   in  whom 
jaundice  coexisted  with  the  typhus  rash  12  died.     As  in  the 
specific  diseases  already  mentioned,  the  jaundice  is  not  due  to 
any  obstruction  of  the  bile-duct;  it  is  likewise  independent  of 
hepatic  congestion.     The  hepatic  tissue  in  the  cases  which  I 
have  had  an  opportunity  of  dissecting  has  been  preternaturally 
pale  and  soft,  all  trace  of  division  into  lobules  has  in  some 
instances  disappeared,  and  the  secreting  cells  have  contained  a 
large  quantity  of  oil  and  have  appeared  to  be  undergoing  dis- 
integration, while  both  Frerichs  and  myself  have  found  leucin 
and  tyrosin  in  both  the  hepatic  and  renal  tissue,  and  also  in 
the  urine. ^     In  one  of  my  cases  (Case  CXXXIII.)  also  it  was 
ascertained  that,  as  in  yellow  atrophy  (see  p.  263),  urea  had 
almost  disappeared  from  the  urine.     Excepting  the  presence 
of  jaundice,  there  is  nothing  very  remarkable  in  these  cases  of 
typhus.     Typhoid  symptoms  are  always  present  in  a  prominent 
degree,  and,  as  I  have  elsewhere  endeavoured  to  show,  these 
symptoms  are  probably  due  to  an  imperfect  elaboration  and 
retention  in  the  system  of  those  products  of  blood-  and  tissue- 
metamorphosis  which  ought  to  be  eliminated  by  the  kidneys. 
Convulsions,    which   may   be   regarded   as   the    acme    of    the 
typhoid  state,  are  now  acknowledged  to  have  a  ursemic  origin 
in  typhus  as  well  as  in  scarlatina,  and  I  have  placed  on  record 
cases  of  typhus,^  without  as  well  as  with  convulsions,  in  which 
urea  has  been  found  in  the  serum  of  the  blood.     When  jaundice 
then  occurs  in  typhus,  it  does  not  account  for  the  other  serious 
symptoms  with  which  it  is  usually  associated,  nor  does  it,  in 
itself,  x^robably  contribute  in  any  way  to  the  fatal  event ;  it  is 
merely  one  indication  of  an  unusual  impurity  and  derangement 
of  the  normal  metamorphosis  of  the  blood,  as  the  result  of 
which  the  absorbed  bile  is  not  transformed  as  in  health,   or 
even  as  in  ordinary  cases  of  typhus. 

Occasionally  jaundice  in  typhus  ^dmits  of  another  exj^lana- 
tion  than  that  now  offered.  Its  appearance  in  Case  CXXXY. 
was  probably  determined  by  the  double  pneumonia,  and  in 
Case   CXXXVI.,  where   it  occurred  during  convalescence,  it 


'  Murchison,  Continued  Fevers  of  Great  Britain.  2nd  ed.  1873,  p.  210. 
2  See  my  -work  on  Fevers,  pp.  161,  174. 


LBCT.  XI.  ■WITHOUT   OBSTRUCTION    OF    BILE-DUCT.  4OI 

seemed  due  to  a  condition  approaching  tliat  of  pysemia,  rather 
than  to  be  a  direct  result  of  typhus. 

e.  Enteric  or  Pythogenic  Fever. 

I  have  met  with  jaundice  in  only  four  cases  of  enteric  fever, 
of  which  three  were  fatal.     In  one  (Case  CXXXVII.)  which 
recovered,  it  occurred  during  a  relapse  of  the  fever,  and  was 
probably  due  to  catarrh  of  the  bile-duct;  in  a  second  (Case 
CXXXIX.),  it  appeared  on  the  fourteenth  day  and  was  asso- 
ciated with  albuminuria,  and  during  convalescence  with  throm- 
bus of  the  femoral  veins ;  the  albuminuria  persisted,  and  the 
patient  died  within  six  months.     In  the  remaining  two  cases  the 
jaundice  occurred  during  the  primary  fever ;  both  were  fatal ; 
and  in  both  the  liver  after  death  was  found  to  be  small,  and  its 
secreting  cells  loaded  with  oil.     In  a  fifth  case  communicated  to 
me  (Case  CXXXIX.),  the  jaundice  came  on  towards  the  termina- 
tion of  a  severe  attack  and  persisted  through  convalescence.     A 
case  is  recorded  by  Andral  where  the  jaundice  was  noted  at 
the  commencement  of  the  third  day,  and  where  the  x)atient 
died  on  the  ninth  day  of  pneumonia  of  the  left  lung.^     Louis 
has  recorded  two  fatal  cases,  one  of  which  was  associated  with 
parotid  bubo  and  secondary  purulent  deposits  in  the  liver,  and 
the  other  with  erysipelas  of  the  leg.^     Sir  W.  Jenner  never 
met  with  jaundice  in  enteric  fever,  but  refers  to  a  preparation 
from  a  fatal  case  which  occurred  on  the  west  coast  of  Africa. 
Two  fatal  cases  are  recorded  by  Frerichs.^     In  one  the  jaundice 
did  not  appear  until  the  thirty- seventh  day,  when  the  patient 
appeared  to  be  convalescent,  and   on  the  forty-first  day  the 
patient  died  with  symptoms  of  pulmonary  oedema ;  the  urine 
was  scanty,  and  after  death  the  kidneys  were  found  to  be  con- 
gested, while  leucin  and  tyrosin  were  discovered  in  the  hepatic 
tissue.     In  the  other  the  jaundice   appeared  as  early  as  the 
fifth  day,  and  was  accompanied  by  profuse  epistaxis  and  violent 
delirium  ;  death  occurred  on  the  eighth  day  before  the  com- 
mencement of  ulceration  in  the  ileum,  and  the  liver  was  found 
to  be  in  a  state  of  acute  yellow  atrophy.     Jaundice  appears  to 
be  on  the  whole    a  rarer  symptom  in   enteric  fever   than   in 
typhus,  and  of  the  few  cases  where  it  occurs  in  some  the  jaun- 
dice is  probably  due  to  catarrh  of  the  bile-duct.     In  others, 

'  Cliniqiie  Medicale.  3me  ed.  1834,  torn.  i.  p.  10. 

'  Eecherches  sur  la  Fi^vre  typhoide,  2me  ed.  Paris,  1841,  Obs.  17  and  26. 

3  Op.  cit.  vol.  i.  pp.  172,  215 

D  D 


402  JAUNDICE,  LKCT.  XI, 

however,  its  patholopry  appears  to  be  the  same  as  that  of  jaun- 
dice in  the  specific  diseases  aheady  considered. 

/.  Scarlatina. 

Yon  -will  find  in  Dr.  Graves's  Clinical  Lectures  (vol.  i.  jd. 
453)  two  cases  of  scarlatina  referred  to  which  were  complicated 
with  jaundice  and  enlargement  of  the  liver  and  ascribed  to  hepa- 
titis, and  that  a  chronic  form  of  hepatitis  is  spoken  of  as  a 
common  sequel  of  scarlet  fever.  Dr.  G.  Harley  has  also  re- 
lated a  case  of  scarlet  fever  complicated  with  jaundice  from 
what  was  believed  to  be  congestion  of  the  liver.^ 

From  my  own  experience  I  am  led  to  the  conclusion  that 
jaundice  in  scarlet  fever  is  extremely  rare.  Out  of  about  2,000 
cases  that  came  under  my  care  prior  to  18G8,  it  occurred  in 
only  five.  Three  of  the  five  cases  were  fatal.  In  two  of  the 
fatal  cases  an  autopsy  was  performed  ;  in  one  the  liver  was 
not  congested  in  the  slightest  degree,  but  -was  pale  and  fatty 
(Case  CXLI.)  ;  in  the  other  (Case  CXL.)  it  presented  a  nut- 
meg appearance,  the  margins  of  the  lobules  being  pale  and 
their  centres  full  of  blood ;  in  both  cases  the  bile-ducts  were 
perfectly  patent ;  the  urine  in  both  cases  contained  albumen, 
but  it  is  to  be  regretted  that  no  examination  was  made  for 
leucin  or  tyrosin.  It  is  very  probable  that  when  jaundice 
appears  in  sca,rlet  fever  it  may  be  sometimes  due  to  hepatic  con- 
gestion or  to  catarrh  of  the  bile-ducts ;  but  in  other  cases,  and 
these  are  the  more  fatal,  it  is  evidently  independent  of  conges- 
tion or  of  obstruction  of  the  ducts,  and  is  probably  the  result 
of  serious  derangements  in  the  metamorphoses  of  the  blood. 

g.  '  Eindemic  Jaundice.'' 

Most  writers  on  jaundice  refer  to  its  occasional  occurrence 
in  the  epidemic  form.  You  will  find  an  account  of  several 
epidemics  of  jaundice  in  Frerichs's  work  on  the  Liver.^  These 
epidemics  have  varied  greatly  in  their  fatality,  and  probably 
also  in  their  nature.  In  some,  not  a  single  patient  has  died. 
This  was  the  case  in  an  epidemic  at  Chasselay,  referred  to  by 
Frerichs,  where  the  jaundice  commenced  with  gastric  catarrh 
and  the  stools  were  always  pale.  A  similar  observation  was 
made  at  Paviain  1859.  Of  1,022  French  troops  stationed  there, 
71  were  attacked  with  jaundice,  but  all  recovered  ;  the  cases 

'  Patholopy  and  Treatmeut  of  Jaundice,  p.  93. 
*  Op.  cit.  i.  p.  188. 


LECT.  XI.  WITHOUT    OBSTRUCTION    OF    BILE-DUCT.  4O3 

were  cliaracterisecl  by  pain  in  the  epigastrium  and  livpochon- 
dria  andby  enlargement  of  the  liver  and  spleen  ;  and  the  epidemic 
was  attributed  to  marah  miasmata,  conjoined  with  unusual 
heat,  fatigue,  and  intemperance.'  On  the  other  hand,  in  an 
epidemic  which  prevailed  at  Essen  in  1772,  which  attacked 
chiefly  children,  assumed  an  intermittent  type,  and  was  cha- 
racterised by  delirium  and  other  nervous  symptoms,  a  large 
proportion  of  the  patients  perished.  In  another  epidemic 
which  occurred  in  the  island  of  Martinique  in  1858  the  disease 
was  extremely  fatal  among  pregnant  females ;  of  30  women 
attacked  at  St.  Pierre  during  pregnancy  20  aborted  and  died, 
death  being  preceded  by  delirium,  coma,  and  other  symptoms 
closely  resembling  those  of  acute  atrophy  of  the  liver.^  In 
1862  a  remarkable  epidemicof  jaundice  occurred  at  Eotherham, 
where  the  condition  of  the  drainage  was  notoriously  bad.  In  the 
autumn  of  that  year  Eotherham  was  visited  by  a  very  fatal  out- 
break of  enteric  fever.  This  was  followed  by  an  epidemic  of 
jaundice  early  in  the  following  year,  and  in  the  month  of 
February  it  was  stated  that  not  fewer  than  150  persons  were 
suffering  from  it,  but  that  none  who  had  passed  through  the 
fever  in  the  previous  autumn  had  been  attacked.^  According 
to  Sir  Thomas  Watson,  jaundice  was  epidemic  in  London  in 
1846,  just  after  the  prevalence  of  extremely  hot  weather,"  * — 
a  season  which  was  also  remarkable  for  an  unusual  prevalence 
of  enteric  fever. 

Most  of  these  epidemics  seem  to  have  been  due  to  some 
malarious  poison  (see  antea,  p.  ]  54) ;  some  perhaps  may  have 
resulted  from  a  chill  or  other  atmospheric  influence.  The 
mechanism  of  the  jaundice  has  probably  varied  with  the  severity 
of  the  epidemic.  Sometimes  it  appears  to  have  been  occasioned 
by  congestion  of  the  liver  or  catarrh  of  the  bile-ducts,  but  in 
others  where  it  was  accompanied  by  delirium  and  typhoid 
symptoms  and  was  extremely  fatal,  and  where  the  whole  phe- 
nomena bore  a  close  resemblance  to  those  of  acute  or  yellow 
atrophy  of  the  liver,  it  has  more  probably  been  due  to  morbid 
conditions  of  the  blood  interfering  with  the  normal  metamor- 
phoses. I  have  already  told  you  that  jaundice  which  in  the 
first  instance  appears  purely  catarrhal  may  terminate  fatally 
with  symptoms  of  acute  atrophy  (p.  267). 

'  Medical  Times  and  Gazette,  June  8,  1861,  p.  607. 

"  Brit.  Med.  Journ.  Feb.  7,  1863. 

»  Lancet,  1863,  vol.  i.  pp.  222,  37'i.  *  Op.  cit.  5tli  ed.  ii.  683. 

D   D   2 


404  JAUNDICE, 


2.  Animal  Poisons. 

a.  Pycemia. 

In  a  large  proportion  of  cases  of  pyaBmia,  whether  from  ex- 
ternal wounds  or  injuries,  from  parturition,  or  from  internal 
causes  (see  p.  166),  there  is  jaundice  of  the  skin,  conjunctivae, 
and  urine.  Many  cases  of  this  sort  came  under  my  notice 
in  the  London  Fever  Hospital.  The  jaundice  usually  com- 
mences early  in  the  disease  and  continues  to  increase  till 
death ;  but  it  is  rarely  intense,  and  sometimes  it  is  so  slight 
that  it  is  apt  to  be  overlooked.  The  bowels  are  usually  relaxed 
and  the  evacuations  contain  plenty  of  bile.  Occasionally,  as  I 
have  explained  to  you  in  a  former  lecture  (see  p.  164),  the 
liver  is  found  to  contain  purulent  deposits,  but  in  most  eases 
nothing  can  be  detected  in  it  to  account  for  the  jaundice.  The 
organ  is  pale  and  anaemic,  and  the  bile-ducts  are  patent  and 
free  from  inflammation  (see  Case  CXLTV.).*  The  urine,  in 
addition  to  bile-pigment,  often  contains  albumen  or  blood,  in- 
dicating a  condition  of  the  kidneys  unfitting  them  for  elimi- 
nating the  large  quantity  of  urea  which  is  manufactured  in 
pyaemia  in  common  with  other  pyrexial  diseases.  In  most 
cases  of  pyaemia  the  tongue  after  a  time  becomes  dry  and 
brown,  and  there  are  more  or  less  stupor  and  delirium,  and 
in  fact  all  the  phenomena  of  the  typhoid  state  met  with  in 
typhus  and  in  other  diseases.  The  abnormal  condition  of  the 
metamorphic  processes  going  on  in  the  blood  and  the  accumu- 
lation in  the  blood  of  the  i)roducts  of  metamorphosis  which 
ought  to  be  eliminated  by  the  kidneys,  to  which  this  typhoid 
state  is  due,  lead  also  to  an  impaired  consumption  of  the  bile 
which  has  been  absorbed  into  the  blood  and  account  for  the 
jaundice. 

h.  Snalce-bites. 

Since  the  days  of  Galen  it  has  been  known  that  the  bites  of 
snakes  and  vipers  occasionally  cause  jaundice.  The  jaundice 
may  be  intense,  and  what  is  very  remarkable  is  the  rapidity 

'  Virchow  lias  mainbiincd  that  the  jaundico  in  pjaeniia  (as  woll  as  in  typhus) 
is  catarrlial,  and  due  to  a  plug  of  viscid  mucus  in  the  duodenal  orifice  of  the  duct 
(Virchow's  Archiv,  1865,  xxxii.  lift  i.).  Aceordinj^  to  Frerichs.  howpver,  'the  bile- 
ducte  are  open  and  usually  pour  out  a  little  thin  secretion,'  and  this  coincides  with  my 
own  experience.  Moreover,  the  fact  that  the  stools  always  contain  bile  and  that  the 
jaundice  is  in  most  cases  slight  are  opposed  to  this  being  the  result  of  mechanical 
obstruction  of  the  duct. 


tECT.  XI.  WITHOUT    OBSTRUCTION    OP    BILE-DUCT.  405 

with  wliicli  it  is  sometimes  developed.  Speaking  of  cases  of 
this  sort,  Dr.  Mead  long  ago  observed,  '  intra  non  integram 
horam  fit  flavus,  quasi  ejus  qui  ictero  laborat.'' 

Careful  records  of  post-mortem  examinations  in  cases  where 
death  has  been  due  to  snake-bites  are  still  wanting,  but  it  is 
clear  that  the  jaundice  is  independent  of  any  obstruction  of  the 
gall-duct,  as  the  vomited  matters  and  stools  always  contain 
bile.  The  very  rapidity  also  with  which  the  jaundice  is  deve- 
loped is  opposed  to  its  immediate  cause  being  congestion  of  the 
liver,  and  suggests  the  idea  that  it  is  the  result  of  disordered 
innervation,  whereby  there  is  induced  an  abnormal  condition 
of  the  metamorphic  processes  going  on  in  the  blood.  The 
general  symptoms  resulting  from  snake-bites, — viz.  a  quick 
small,  irregular  pulse,  tendency  to  fainting,  bilious  vomiting, 
difficult  breathing,  cold  perspiration,  dulness  of  vision,  derange- 
ment of  the  mental  faculties  and  sometimes  convulsions,^  all 
point  to  serious  derangement  of  the  nervous  system. 

3.  Mineral  Poisons. 

a.  Pliospliorus . 

During  the  last  few  years  numerous  cases  have  been  re- 
corded both  in  this  country  and  on  the  Continent  of  acute 
poisoning  by  phosphorus,^  which  are  remarkable  in  this  respect, 
that  in  almost  every  instance  jaundice  has  been  one  of  the 
symptoms  noticed.  I  do  not  refer  here  to  those  cases  of 
chronic  poisoning  by  phosphorus  where  there  is  necrosis  of  the 
jaw,  so  common  in  persons  engaged  in  the  manufacture  of 
lucifer- mate  lies,  but  to  cases  where  acute  symptoms  have 
followed  one  large  dose  of  the  poison.  There  has  been  much 
discussion  as  to  what  is  the  pathology  of  the  jaundice  in  these 
cases.  Virchow  and  other  observers  maintain  that  it  is  due  to 
obstruction  of  the  duodenal  end  of  the  bile-duct  by  thickening 
of  the  mucous  membrane  and  a  plug  of  mucus,  and  that 
although  the  stomach  and  duodenum  have  often  been  found  to 
present  no  redness  nor  obvious   sign  of  inflammation,  there  is 

'  Tentaraen  de  Vipera,  p.  36. 

2  Christison  on  Poisons,  1829,  p.  470. 

^  An  account  of  many  of  these  eases  will  be  found  in  the  Year  Books  of  the 
Sydenham  Society,  1859,  p.  445;  1860,  p.  440;  1861,  p.  409;  1862,  p.  428;  1863, 
p.  404  ;  1864,  p.  423;  and  Biennial  Eetrospects,  1865-6,  p.  434 ;  1867-8,  p.  448; 
1869-70,  p.  453.  Two  cases  are  also  recorded  in  the  Fiftieth  volume  of  the  Medico- 
Chirurgical  Transactions  by  Drs,  Habershon  and  Hillier. 


406  JAUNDICE,  LECT.  XI. 

nevertheless  a  '  cloudy  swelling '  of  the  gastric  glands  and 
thickening  of  the  whole  membrane.'  Dr.  0.  Wyss,  however, 
has  shown  that  when  dogs  with  a  biliary  fistula  were  poisoned 
with  phosphorus  jaundice  was  produced,  which  could  not 
therefore  be  due  to  obstruction  of  the  intestinal  portion  of  the 
common  bile-duct.  After  the  appearance  of  jaundice  much 
less  bile  escaped  by  the  fistula,  and  that  little  was  mixed  with 
colourless  mucus ;  sometimes  mucus  alone  escaped.^  This 
observation  is  interesting  in  connection  with  the  fact,  that 
almost  all  the  descrijjtious  of  the  post-mortem  appearances 
agree  in  stating  that  the  liver  is  in  an  extreme  state  of  fatty 
degeneration,  and  that,  as  in  acute  atroi)l\Y,  the  secreting 
functions  of  the  organ  have  been  in  a  great  measure  abrogated. 
The  appearance  of  the  liver,  in  fact,  has  in  many  instances 
resembled  very  closel}'  that  of  yellow  atrophy.  The  symptoms 
moreover  of  acute  phosphorus-poisoning — drowsiness  followed 
by  violent  delirium,  convulsions  and  coma,  vomiting,  albu- 
minous or  bloody  urine,  in  which  C.  Schultzen  ^  has  discovered  a 
substance  closely  allied  to  tyrosin,  and  a  fluid  condition  of  the 
blood  with  petechias  and  haemorrhages — are  utterly  unlike 
those  of  catarrhal  jaundice,  and  so  closely  resemble  those 
of  acute  atroj)liy  of  the  liver,  that  it  has  even  been  sug- 
gested that  many  of  the  recorded  instances  of  acute  atrophy 
have  been  really  cases  of  phosphorus-poisoning.^  It  seems 
probable  therefore  that  the  jaundice  of  phosphorus-poisoning 
has  a  blood  origin,  and,  like  that  of  yellow  fever  and  typhus, 
must  be  ascribed  to  an  abnormal  condition  of  the  metamor- 
phoses in  the  blood. 

h.  Mercury,     c.  CojJpcr.     il.  Antimony. 

The  j)reparations  of  mercury,  copper,  antimony,  and  other 
irritant  poisons  have  been  known  to  cause  jaundice,  but  only 
in  exceptional  cases.  The  mode  of  production  of  the  jaundice 
has  not  been  well  ascertained,  but  the  most  probable  explana- 

'  Archiv  f.  pnth.  An;it.  u.  Phys.  xxxi.  p.  399. 

'''  Archiv  der  lleilkunde,  18G7,  p.  419. 

'  Ueber  acute  I'liosphorvergi flung  und  acute  Loljcriitrophie,  Berlin,  1869,  pp.  29, 
y2,  36. 

*  See  for  inKtaiice  leferences  in  Syd.  Soc.  Year  Book  for  1862,  pp.  428,  430,  and 
for  1863,  p.  404.  The  points  of  differential  diagnosis  which  II.  Koiiler  (Schmidt's 
Jahrb.  No.  147,  p.  148)  has  drawn  between  acute  atrophy  of  the  liver  and  phosphorus- 
pjisouing  will,  I  am  satisfied,  not  always  hold  good  at  the  bedside. 


LBCT.  XI.  WITHOUT    OBSTRUCTION    OF    BILE-DUCT.  40/ 

tion  is  that  it  is  caused  by  the  inflamed  and  swollen  state  of 
the  mucous  membrane  blocking  up  the  duodenal  orifice  of  the 
bile-duct. 

4.  Chloroform  and  Ether. 

Chloroform  and  ether,  according  to  Frerichs,^  occasionally 
cause  jaundice,  while  several  observers  have  found  that  under 
their  influence  sugar  passes  ofi"  in  the  urine.  The  concomitant 
symptoms  of  jaundice  from  these  substances  are  little  known, 
and  the  cases  are  extremely  rare,  for  after  considerable  search 
I  have  been  unable  to  find  the  records  of  any.  Most  probably 
the  jaundice  has  a  blood  origin,  but  its  precise  mode  of  pro- 
duction has  still  to  be  determined. 

5.  Acute  Atrophy  of  the  Liver. 

In  a  former  lecture  (see  pp.  260,  270)  I  have  shown  you 
that  the  jaundice  in  that  remarkable  disease,  acute  or  yellow 
atrophy  of  the  liver,  is  independent  of  obstruction  of  the 
bile-ducts,  and  that  it  is  probably  the  result  of  some  abnormal 
condition  of  the  blood.  The  motions  during  life  usually  contain 
bile,  and  after  death  the  gall-ducts  are  found  to  be  per- 
fectly patent,  while  on  the  other  hand  all  the  phenomena  of 
the  disease  approximate  it  to  those  maladies  which  are  known 
to  result  from  some  poison,  such  as  typhus,  enteric  fever, 
pygemia,  and  phosphorus-poisoning.  I  need  only  recall  to  your 
recollection  the  fact,  already  adverted  to  in  this  lecture,  of 
leucin  and  tyrosin  being  found  in  the  jaundice  of  typhus  in 
common  with  that  of  acute  atropliy,  and  the  circumstance  of 
the  liver  being  found  in  a  state  of  acute  atrophy  in  a  case  of 
enteric  fever  complicated  with  jaundice.  It  becomes  a  question, 
indeed,  whether  the  condition  of  the  li^er  in  acute  atrophy  be 
the  cause  of  all  the  formidable  symptoms  with  which  it  is  asso- 
ciated, or  whether  it  be  not  rather  merely  one  of  the  con- 
sequences of  some  general  disorder  of  the  system,  like  that 
which  is  produced  by  many  poisons.  On  a  former  occasion  I 
told  you  that  it  had  been  repeatedly  observed,  that  several  of 
the  residents  in  the  same  house  had  been  attacked  with  acute 
atrophy  almost  simultaneously  (p.  266).  There  is  good 
rea.son  also  for  believing  that  some  of  the  instances  of  '  epidemic 
jaundice '  have  been  examples  of  acute  atrophy.  In  the 
epidemic,    for    instance,    which   prevailed    in    the    island    of 

'  Op.  cit.  vol.  i.  p.  160. 


408  JAUNDICE,  LECT.  XI. 

Martinique  in  1858,  the  jaundice  was  accompanied  by  delirium, 
coma,  and  other  symptoms  of  acute  atrophy,  and,  as  in  acute 
atrophy,  the  disease  was  especially  frequent  and  fatal  in 
pregnant  females,  who  aborted  before  death.  It  is  a  matter 
for  investigation  whether  the  anatomical  changes  which  are  so 
notably  present  in  the  liver  in  cases  of  acute  atrophy  are  really 
limited  to  that  organ.  Wagner,  who  is  of  opinion  that  many 
of  the  recorded  instances  of  acute  atrophy  were  probably  cases 
of  acute  poisoning  by  phosphorus,  on  the  ground  of  their 
complete  clinical  and  pathological  analogy  with  cases  known  to 
be  of  this  nature,  has  drawn  attention  to  the  almost  universal 
infiltration  of  every  tissue  of  the  body  with  oil  in  cases  where 
death  has  been  due  to  phosj^horus,  whereas  this  change  had 
been  previously  recognised  only  in  the  liver.  He  found  minute 
fat-granules  in  the  epithelium  of  the  kidneys,  in  the  parenchyma 
of  the  lungs,  and  in  the  muscular  fibres  of  the  voluntary  muscles 
and  of  the  heart.  These  observations  have  been  confirmed  by 
other  investigators,  and  while  Bucquoy,^  Buhl,^  and  Steiner^ 
have  discovered  in  the  brain  a  fatty  destruction  similar  to  that 
which  is  found  in  the  liver,  kidneys,  and  heart,  one  cannot 
fail  to  be  struck  with  the  analogy  which,  in  this  respect,  cases 
of  j)hosphorus-poisoning  bear  to  typhus,  in  which,  as  we  have 
found,  jaundice  with  leucin  and  ty rosin  is  apt  to  be  developed. 
It  is  now  well  known  that  a  granular  degeneration  of  the 
voluntary  muscles  of  the  heart  and  of  the  renal  epithelium  is 
among  the  most  common  post-mortem  appearances  in  typhus, 
and  probably  in  most  diseases  where  death  has  been  preceded 
for  some  time  by  the  typhoid  state.  Speaking  of  the  kidneys 
in  acute  atrophy  of  the  liver,  Frerichs  observes :  "*  '  I  have 
found  the  glandular  epithelium  infiltrated  with  granules,  and 
in  most  cases  in  a  state  of  fatty  degeneration,  and  the  tissue 
itself  flabby  and  shrivelled.'  Frerichs  also  speaks  of  '  a  flabby 
shrivelled  character  of  the  muscular  tissue  of  the  heart,'  and 
states  that,  '  in  some  cases  the  cerebral  substance  has  appeared 
softened,'  although  he  expresses  doubts  whether  this  condition 
was  the  result  of  commencing  putrefaction,  or  a  product  of 
disease.  There  seems  reason  then  for  believing  that  the  con- 
dition of  the  liver  in  acute  atrophy  is  only  one  of  many  similar 
changes  taking  place  throughout  the  body,  as  the  result  of  some 


'  Union  MWicale,  1863,  No.  81.  ^  Zeitschi-ift  fiir  rat.  Med.,  1852. 

'  Compcnd.  dor  Kinderkraukbciten,  1873,  301.  *  Op.  cit.  i.  227. 


LECT.  XI.  WITHOUT    OBSTRUCTION    OP    BILE-DUCT.  409 

blood-poison.  Trousseau  indeed  maintains  that  tlie  symptoms 
of  acute  atrophy  (malignant  jaundice)  can  exist  without  any 
lesion  of  the  liver,  which  cannot  therefore  be  the  cause  of  the 
change  in  the  blood. ^ 

Dr.  Grainger  Stewart  has  advanced  our  knowledge  a  step 
further  by  recording  cases  showing  that  acute  atrophy  of  the 
kidneys  may  not  only  coexist  with  acute  atrophy  of  the  liver, 
but  that  the  morbid  process  in  the  kidneys  may  precede  that 
in  the  liver.  ^ 

6.   Cirrhosis  and  Chronic  Atro-phy  of  the  Liver. 

In  a  former  lecture  (p.  281)  I  have  pointed  out  to  you  that 
in  the  advanced  stages  of  cirrhosis  of  the.  liver,  jaundice 
associated  with  cerebral  symptoms  and  haemorrhages  is  not 
uncommon.  The  motions  in  these  cases  are  usually  well- 
coloured  with  bile,  and  the  pathology  of  the  jaundice  is  pro- 
bably the  same  as  that  of  acute  atrophy.  The  jaundice  is 
usually  slight,  gradual  in  its  onset,  and  attended,  rarely  by 
pain,  but  often  by  ascites. 

II.  IMPAIRED  OR  DERANGED  INNERVATION  INTERFERING  WITH 
THE  NORMAL  METAMOEPHOSIS  OF  BILE  OR  INCREASING  THE 
SECRETION. 

That  jaundice  may  have  a  nervous  origin  has  long  been 
known.  There  are  numerous  instances  on  record  of  its  being 
produced  by  severe  mental  emotions,  such  as  fits  of  angerj 
fear,  shame,  or  great  bodily  suffering.  Concussion  of  the 
brain  has  been  known  to  have  a  like  effect.  Villeneuve  relates 
the  case  of  a  young  soldier,  who,  being  insulted  in  public,  drew 
his  sword  and  would  have  rushed  upon  the  aggressor,  but  was 
restrained  by  the  bystanders  ;  in  his  vain  eftbrts  to  wreak  his 
vengeance,  he  became  suddenly  jaundiced ;  soon  afterwards 
delirium  set  in  and  he  died  in  convulsions.  He  also  quotes 
the  case  of  a  young  abbe,  who,  owing  to  a  sudden  fright  from  a 
mad  dog  breaking  its  chain  and  rushing  at  him,  uttered  a  loud 
cry,  fell  down  unconscious,  and  was  taken  up  as  yellow  as 
saffron.^  Mr.  JSTorth  witnessed  a  case  in  which  an  unmarried 
female,  on  its  being  accidentally  disclosed  that  she  had  borne 

>  Clin.  Lect.,  Syd.  Soc.  Ed.  it.  312. 

^  Bright's  Diseases  of  the  Kidneys,  1868,  p.  159. 

^  Diet,  des  Sciences  Med.,  1818,  Art.  Ictere,  p.  420. 


410  JAUNDICE,  LKCT.  XI. 

children,  became  in  a  very  short  time  yellow ;  and  a  young 
medical  friend  of  Sir  Thomas  Watson  had  an  attack  of 
intense  jaundice,  which  could  be  traced  to  nothing  else  than 
his  great  and  needless  anxiety  about  an  approaching  examina- 
tion before  the  Censors'  Board  of  the  College  of  Physicians.' 
There  are  two  circumstances  worth}^  of  note  in  these  cases : — 

1.  The  rapidity  with  which  the  jaundice  is  developed,  the  skin 
and  conjunctivte  become  yellow  almost  in  a  moment,  and  even 
before  the  appearance  of  any  bile-pigment  in  the  urine  ;  and, 

2.  That  cerebral  symptoms,  such  as  delirium,  coma,  and  con- 
vulsions, often  supervene  upon  the  jaundice,  and  that  the  cases 
are  then  often  fatal.  These  characters  seem  incompatible  with 
the  supposition  that  the  jaundice  can  result  from  any  me- 
chanical obstruction  of  the  bile-duct,  or  even  from  congestion 
of  the  liver,  and  make  it  more  probable  that  it  is  caused  by 
some  derangement,  through  nervous  influence,  of  the  natural 
metamorj)hoses  in  the  blood.  In  a  former  lecture  I  have 
told  you  that  the  '  pathemata  mentis '  constitute  one  of  the 
causes  of  the  general  morbid  state  of  which  acute  atrophy 
of  the  liver  is  one  of  the  local  manifestations. 

It  is  very  probable,  however,  as  Dr.  Bence  Jones  has  pointed 
out,2  that  jaundice  has  occasionally  a  nervous  origin  of  another 
sort.  The  circulation  and  secretion  of  all  glands  are  controlled 
by  the  nerves  which  supply  them.  Claude  Bernard  has  shown 
that  if  the  sympathetic  filaments  of  the  sublingual  gland  be 
tetanised,  !:he  blood  in  the  gland  becomes  very  dark,  and  the 
saliva  scanty  and  concentrated ;  but  that  if,  on  the  contrary, 
the  chorda  tympani  alone  be  tetanised,  the  blood  in  the  gland 
presents  an  arterial  hue,  and  the  saliva  is  increased,  though  it 
contains  a  small  proportion  of  solid  matter.  Similar  results 
would  no  doubt  be  produced  in  the  liver.  Irritation  of  the 
sympathetic  or  paralysis  of  the  branches  of  the  pneumogastric 
nerve  would  probably  contract  the  small  blood-vessels  and 
diminish  the  secretion  of  bile,  while  paralysis  of  the  sympa- 
thetic, or  irritation  of  the  pneumogastric,  would  relax  the 
capillaries  and  increase  the  rapidity  of  the  circulation  through 
the  liver  and  the  secretion  of  bile.  Under  these  circumstances 
jaundice  would  be  produced  in  the  way  which  I  shall  explain 
to  you  presently  when  speaking  of  jaundice  from  congestion. 

'  Lect.  on  Pract.  of  Physic,  5tli  od.  vol.  ii.  p.  G82. 
^  iSt.  George's  Hospital  Kcports,  18GG,  vol.  i.  p.  193. 


WITHOUT    OBSTRUCTION    OF    BILE-DUCT.  4I I 


III.    DEFICIENT    OXYGENATION  OF    THE    BLOOD    INTEEFERING    WITH 
THE    NORMAL    METAMORPHOSIS    OF    BILE. 

Whatever  interferes  witli  a  due  supply  of  oxygen  to  the 
blood  interferes  with  those  metamorphoses  which  in  a  healthy 
condition  of  the  body  are  constantly  taking  place  in  it,  and 
may  thus  impede  or  arrest  the  normal  transformation  of  the 
absorbed  bile  and  cause  jaundice.  It  is  deficient  oxygenation 
which  probably  in  a  great  measure  accounts  for  many  of  the 
cases  of  true  jaundice  with  bile  in  the  stools  (see  antea,  pp. 
312,  347)  met  with  in  new-born  infants.  According  to  Dr. 
West,  '  in  the  Dublin  Lying-in  Hospital,  where  the  children 
are  defended  by  the  most  watchful  care  from  the  evils  either  of 
cold  or  of  a  vitiated  atmosphere,  the  occurrence  of  infantile 
jaundice  is  rare :  while  in  the  Foundling  Hospital  in  Paris 
jaundice  is  so  common  that  comparatively  few  infants  escape 
it.  Almost  all  the  children  at  the  Foundling  Hospital  have 
been  exposed  to  the  action  of  cold  while  being  brought  to  the 
institution,  and  suffer  from  the  combined  influence  of  cold 
and  bad  air  while  inmates  of  it — causes  which  interfere  very 
seriously  with  the  due  ^performance  of  the  functions  of  the  skin 
and  of  the  respiratory  organs.'  ^ 

The  jaundice  which  occasionally  accompanies  acute  pneu- 
monia in  the  adult  may  possibly  have  a  similar  origin.  In 
the  course  of  acute  pneumonia  the  skin  and  conjunctivse 
occasionally  become  jaundiced,  and  bile-pigment  appears  in 
the  urine  without  any  disappearance  of  bile  from  the  motions. 
The  pneumonia  in  these  cases  is  far  from  being  always  in.  the 
lower  lobe  of  the  right  lung,  as  some  writers  have  stated.  Of 
19  cases  observed  by  Drasche,  the  inflammation  was  in  the 
right  lung  in  7 — in  5  at  the  base,  in  1  at  the  apex,  and  in  1  in 
the  entire  lung ;  in  8  the  left  lung  alone  was  affected ;  and  in  4 
the  pneumonia  was  double.^  The  jaundice  in  these  cases  is  in- 
dependent of  any  obstruction  of  the  bile-duct,  for,  as  a  rule, 
there  is  no  lack  of  bile  in  the  evacuations  from  the  bowels. 
Various  explanations  have  been  offered  as  to  its  mode  of  pro- 
duction. It  has  been  attributed  to  congestion  of  the  liver 
from  impeded  circulation  through  the  lungs,  and  possibly  hepatic 
congestion  may  also  be  induced  by  nervous  irritation  reflected 

'  Lect.  on  Dis.  of  Infancy  and  Childhood,  5th  ed.  1865,  p.  602. 
^  CEsterrh.  Zeitsch.  f.  prakt.  Heilk.  1860,  No.  23. 


412  JAUNDICE,  LECT.  XI. 

through  the  pneumogastric  nerve  from  the  lungs  to  the  liver. 
Dr.  Bence  Jones  has  recently  suggested  that  the  jaundice  in 
these  cases  is  the  result  of  au  arrest  of  oxydation  in  the  blood. 
These  explanations,  however,  are  not  applicable  in  all  cases. 
In  some  of  the  worst  cases,  the  proportion  of  the  lungs  impli- 
cated in  the  inflammation  is  comparatively  slight,  and  the 
jaundice  is  associated  with  typhoid  symptoms  and  albuminuria. 
The  urine  in  these  cases  is  often  of  a  bright  red  colour,  but, 
what  is  remarkable,  it  is  said  not  always  to  present  the  ordinary 
reaction  of  bile-pigment  with  nitric  acid.  The  absence  of 
bile-pigment  from  the  urine  has  accordingly  been  regarded  as 
an  unfavourable  s^nnptom  in  icteric  pneumonia.  Of  14  cases 
in  which  bile-pigment  was  found  in  the  urine  by  Drasche,  only 
3  died ;  but  of  5  where  the  urine  contained  no  bile-pigment  2 
died.'  It  is  probable  that  in  these  cases  the  jaundice  has  a 
similar  blood-origin  to  that  of  typhus,  pyEemia,  &c.,  which  we 
have  already  considered. 

Deficient  oxj^genation  of  the  blood  from  inhaling  a  vitiated 
atmosphere  in  badly- ventilated  or  overcrowded  apartments  in 
many  instances  no  doubt  induces  'bilious  headaches  '  and  func- 
tional derangement  of  the  liver,  and  may  even  conduce  to  the 
development  of  jaundice. 

IV.    EXCESSIVE  SECRETION    OF  BILE,  MORE    OF  WHICH    IS  ABSORBED 
THAN    CAN    UNDERGO    THE    NORMAL    METAMORPHOSIS. 

If  we  can  suppose  that  in  a  particular  individual  the  oxy- 
genation and  other  processes  of  metamorphosis  going  on  in  the 
blood  are  just  sufficient  to  transform  the  whole  of  the  absorbed 
bile,  it  is  not  difficult  to  understand  that  in  the  event  of  the 
quantity  of  bile  being  increased,  part  of  it  might  not  be 
transformed  and  jaundice  would  be  the  result.  Now  this 
is  probably  what  actually  takes  place  in  cases  of  congestion  of 
the  liver.  The  vessels  of  the  liver  are  distended,  and  the  dif- 
fusing surface  of  the  walls  is  consequently  increased,  and  more 
than  the  normal  quantity  of  bile  is  taken  up  into  the  blood. 
In  many  cases  of  congestion  of  the  liver  the  quantity  of  bile 
secreted  is  also  increased.  This  then  appears  to  be  the  patho- 
logy of  the  jaundice  from  congestion  of  the  liver.  There  is  no 
obstruction  of  the  bile-ducts,  unless  there  be  concurrent  inflam- 
mation of  the  duodenum  or  ducts  (see  p.  132),  and  sometimes, 

'  CEsterrh.  Zeitsch.  f.  prakt,  Iluilk.  1860,  No.  23. 


LECT.  XI.  WITHOUT    OBSTEUCTION   OF    BILE-DUCT.  413 

indeed,  there  is  bilious  diarrlioaa.  If  the  bowels  be  constipated, 
the  jaundice  from  congestion  of  the  liver  will  probably  be  in- 
creased, as  the  bile  instead  of  being  cleared  away  will  accumu- 
late in  the  biliary  passage,  and  will  be  absorbed  in  all  the 
larger  quantity  by  the  distended  vessels.  Mercury,  podophyllin, 
and  other  purgatives  do  good  in  these  cases  by  sweeping  away 
the  bile  as  fast  as  it  flows  into  the  duodenum,  and  perhaps  also 
by  stimulating  the  gall-bladder  and  bile-ducts  to  contract 
through  reflex  action.  As  I  have  formerly  told  you  (pp.  135, 
330),  there  is  no  evidence  that  they  stim.ulate  the  liver  to 
increased  secretion.  If  they  did  they  would  be  injurious  rather 
than  otherwise  in  cases  of  jaundice  from  hepatic  congestion. 

The  symptoms,  varieties,  and  causes  of  hepatic  congestion 
have  been  already  considered  in  a  former  lecture  (see  p.  131). 

V.    UNDUE    ABSORPTIOlSr    OF    BILE    INTO    THE    BLOOD    FROM 
HABITUAL    OE    PROTRACTED    CONSTIPATION. 

I  have  already  explained  to  you  one  way  in  which  jaundice 
may  result  from  constipation,  viz.,  from  the  pressure  of  fseces 
accumulated  in  the  colon  upon  the  bile-duct.  Independently 
of  causing  pressure,  however,  it  is  very  probable  that  a  sluggish 
state  of  the  bowels  -often  contributes  to  the  development  of 
jaundice,  partly  by  impeding  the  portal  circulation  and  in- 
ducing congestion  of  the  liver,  and  partly  by  causing  an 
accumulation  of  bile  in  the  biliary  passages  and  duodenum, 
and  thus  favouring  its  absorption  into  the  blood.  It  is  under 
these  circumstances  that  there  is  often  developed  the  condition 
known  as  'biliousness  from  a  torpid  liver,' where  the  patient 
suflFers  from  languor,  headache,  furred  tongue,  flatulence  and 
constipation,  a  feeling  of  weight  and  oppression  after  meals, 
and  not  uncommonly  hypochondriasis  ;  and,  although  these 
symptoms  may  last  a  long  time  without  actual  jaundice,  this  is 
liable  to  supervene  at  any  time  from  irritating  ingesta,  or  from 
other  causes,  which  increase  the  congestion  of  the  liver.  The 
liver  in  these  cases,  so  far  from  being  '  torpid,'  is  perhaps 
secreting  too  much  bile,  while  mercury  and  other  purgatives 
do  good,  not  as  is  generally  supposed,  by  stimulating  the  liver 
to  increased  secretion,  but  by  getting  rid  of  a  great  portion  of 
the  bile  as  fast  as  it  is  thrown  out,  and  thus  preventing  its 
absorption. 


414  JAUNDICE,  XECT.  XI. 

Treatment  of  Jaundice  independent  of  Obstruction  of  the 
Bile-duct. 

The  treatment  of  jaundice  independent  of  obstruction  of 
the  bile-duct  must  be  regulated  according  to  its  cause. 

1.  In  the  jaundice  from  constipation,  or  in  the  state  of 
'  biliousness '  already  adverted  to  which  is  short  of  actual 
jaundice,  purgatives  must  be  given  in  the  first  place,  and 
of  these  the  best  are  occasional  doses  of  calomel,  blue  pill,  or 
podophyllin,  v^^ith  salines,  such  as  the  sulphates  of  soda,  potash 
and  magnesia,  the  citrate  of  magnesia,  seidlitz  powder  and 
the  bitartrate  of  potash,  or  the  mineral  waters  of  Friedrichshall, 
Piillna,  or  Carlsbad.  Alkalies  and  their  salts  with  the  vege- 
table acids  are  also  useful,  partly  in  correcting  acidity  of  the 
stomach,  but  mainly  by  carrying  off  by  the  kidneys  the  pro- 
ducts of  blood-  and  tissue-metamorphosis,  the  presence  of  which 
in  the  blood  is  the  probable  cause  of  the  languor  and  other 
symptoms  from  which  the  patient  suffers.  At  the  same  time 
fermented  liquors,  wines,  spices,  fat,  and  all  rich  or  indigestible 
articles  of  diet,  which  are  calculated  to  irritate  or  congest  the 
liver,  must  be  forbidden.  These  are  the  measures  most  likely 
to  relieve  the  jaundice  or  'biliousness'  resulting  from  constipa- 
tion. But  the  great  object  of  the  practitioner  in  all  such  cases 
ought  to  be  so  to  modifj'  the  patient's  habits  and  diet  as  to 
secure  if  possible  a  regular  action  of  the  bowels  without  the 
necessity  of  constantly  having  recourse  to  medicine.  It  is 
always  well  to  enjoin  regular  exercise  in  the  open  air  and  the 
use  of  brown  bread,  or  of  such  articles  of  diet  as  the  individual 
knows  from  experience  to  have  an  aperient  effect  upon  the 
bowels ;  and  in  cases  where  purgatives  give  only  temporary 
relief,  more  permanent  benefit  may  be  expected  from  purgative 
mineral  waters,  such  as  those  of  Carlsbad,  Friedrichshall, 
Harrogate,  Cheltenham,  or  Leamington.  When  the  constipa- 
tion and  its  immediate  effects  have  been  relieved,  but  where 
the  patient  still  suffers  from  weakness  and  symptoms  of  atonic 
dyspepsia,  the  mineral  acids  in  conjunction  with  the  vegetable 
bitters,  such  as  nux  vomica,  quinine,  gentian,  or  cascarilla,  or 
with  pepsin,  may  be  expected  to  do  good  ;  while  the  bowels 
are  kept  open  by  a  daily  pill  of  aloe^,  nux  vomica,  and  soap. 

2.  The  treatment  which  is  appropriate  in  cases  of  jaundice 
dependent  upon  congestion  of  the  liver  we  have  already  con- 
sidered, when  treating  of  congestion  as  one  of  the  causes  of 


LECT.  XI.  "WITHOUT    OBSTRUCTION    OF    BILE-DUCT.  415 

enlargement  of  the  organ  (see  p.  134).  It  is  necessary  to 
remember  that  some  of  the  cases  of  jaundice  occurring  in  the 
course  of  malarious  and  other  fevers,  or  of  pneumonia,  or  having 
a  nervous  origin,  are  due  to  hepatic  congestion,  and  that  then 
the  treatment  must  be  modified  in  conformity,  with  the  nature 
of  the  primary  disease  or  cause. 

3.  In  the  jaundice  arising  from  deficient  oxygenation,  the 
chief  treatment  must  be  the  removal  of  the  cause.  In  the 
jaundice  of  infants,  which  is  independent  of  obstruction  of  the 
bile-duct,  the  first  thing  to  be  done  is  to  put  the  child  in  a 
wholesome  atmosphere  and  to  avoid  exposing  it  to  cold.  The 
jaundice  will  then  often  disappear  spontaneously  without  fur- 
ther treatment ;  but  if  it  persist,  a  small  dose  of  hydrargyrum 
cum  creta,  followed  by  castor  oil,  will  often  hasten  its  disap- 
pearance. 

4.  Lastly,  in  those  terrible  cases  of  jaundice  associated 
with  cerebral  symptoms  and  the  typhoid  state,  whether  occurring 
in  the  course  of  malarious  or  infectious  fevers,  or  in  pyaemia, 
pneumonia,  or  the  acute  yellow  atrophy  of  the  liver,  or  having 
a  purely  nervous  origin,  it  is  not  often  that  treatment  is  of  much 
avail  in  averting  a  fatal  result,  but  the  measures  most  likely 
to  do  good  are  those  which  I  have  already  recommended  when 
speaking  of  the  treatment  of  acute  yellow  atrophy  (see  p.  267). 
Blisters  \  and  sinapisms  to  the  nape  and  scalp,  sinapisms 
to  the  feet,  and  remedies  calculated  to  promote  elimination 
by  the  skin,  kidneys,  or  bowels,  are  sometimes  of  service. 
At  the  same  time  it  will  be  necessary  to  support  the  patient's 
strength  by  diffusible  stimulants  and  small  quantities  of  al- 
cohol. 

The  following  cases  illustrate  the  remarks  now  made  on  the 
subject  of  jaundice  independent  of  any  obstruction  of  the  bile- 
duct.  Most  of  them  occurred  in  my  practice  at  the  London 
Fever  Hospital,  where  illustrations  of  the  typhoid  state,  not 
only  in  the  various  specific  fevers,  but  in  many  other  diseases, 
are  probably  more  numerous  than  in  all  the  other  hospitals  of 
the  metropolis  put  together. 

'  It  is  well  to  avoid  cantharides  for  blistering  purposes  in  these  cases,  when  the 
urine  contains  albumen  ;  but  a  blister  can  be  readily  produced,  even  on  the  scalp,  by 
applying  to  the  skin  for  three  or  four  minutes  a  piece  of  lint  moistened  with  strong 
liquor  ammonise,  and  covered  with  oiled  silk.  I  have  repeatedly  produced  a  blister 
in  this  way  with  the  best  effect  in  cases  of  typhus  complicated  with  albumimma  and 
cerebral  symptoms. 


41 6  JAUNDICE,  I.ECT.  XI. 

Tlie  first  three  cases  are  examples  of  jaundice  occurring  in 
the  course  of  typhus  fever — an  event,  as  I  have  told  you,  of 
extreme  rarity.  In  two  of  the  cases  leucin  and  tyrosin  were 
found  in  the  urine  :  in  the  remaining  cases  they  were  not  looked 
for. 

Case  CXXXIII. — Ti/phns  comjoUcated  ivith  Jaundice — Death  by  Coma. — 
Leucin  and  Tyrosin^  hut  scarcely  any  Urea,  in  Urine — Leucin  and 
Tyrosin  in  Liver  and  Kidneys. 

Robert  R ,   aged   33,  admitted  into    London   Fever   Hospital 

August  26,  1862. 

On  admission,  was  too  confused  to  given  any  account  of  himself  ; 
pulse  120,  feeble  ;  tongue  dry  and  brown  along  centre  ;  skin  warm 
and  dry,  with  distinct  typhus-rash,  and  a  general  yellowish  tint.  Was 
ordered  beef-tea,  milk,  brandy  (6  oz.),  and  a  mixture  containing 
sulphuric  acid,  sulphuric  ether,  and  quinine. 

Patient  became  weaker  and  more  unconscious.  On  28th,  decided 
jaundice  of  entire  skin  and  of  conjunctivEe ;  brandy  was  increased  to 
8oz. 

Augttst  29. — Pulse  120  and  feeble  ;  scarcely  conscious,  and  incHncd 
to  be  drowsy  ;  pupils  contracted.  Decided  jaundice  of  skin  and  con- 
junctivae, and  at  same  time  a  well-marked  petechial  typhus-rash  on 
chest  and  abdomen.  Involuntary  evacuations  ;  tongue  brown  ;  motions 
light-coloured,  but  contain  bile ;  no  tenderness  in  hepatic  region. 
Urine  of  a  bilious  colour,  but  does  not  yield  reaction  of  bile-acids  ; 
clear,  acid,  throws  down  no  deposit,  and  contains  no  albumen ;  specific 
gravity  1017.  Six  oz.  of  urine  were  evaporated,  and  residuum 
was  found  to  contain  abundance  of  globular  masses  of  leucin  and 
needle-shaped  crystals  of  tyrosin,  and  also  crj-stals  of  triple  phosphate. 
When  nitric  acid  was  added  to  a  drop  of  urine,  after  concentration  to 
one-twelfth  of  its  volume,  only  a  few  small  crystals  of  nitrate  of  urea 
could  be  discovered  with  the  microscope.  A  blister  was  applied  to  the 
scalp  ;  but  patient  died  comatose,  at  3  p.m  on  Aug.  30. 

Antojjsy. — Deep  jaundiced  tint  of  entire  surface.  Heart  and  lungs 
healthy ;  blood  fluid  and  dark.  Spleen,  7  oz.,  very  soft.  Gall- 
bladder contained  bile,  which  on  squeezing  flowed  readily  into 
duodenum.  Liver,  62  oz.,  rather  pale  and  very  friable,  but 
loljules  distinct ;  hepatic  tissue  contained  numerous  globular  crystal- 
line masses  of  leucin  and  tyrosin  ;  secreting  cells  loaded  with  oil  and 
bile-pigment.  Kidneys  enlarged,  each  weighing  upwards  of  7  oz.  ; 
surfaces  smooth ;  cortex  hypertrophied  and  containing  crystalline 
bodies,  similar  to  those  found  in  liver;  uriniferous  tubes  gorged  with 
epithelium.  Intestines  healthy,  and  their  contents  well  coloured  with 
bile. 


LECT.  xr.  WITHOUT   OBSTRUCTION    OF    BILE-DUCT.  41/ 

Case  CXXXIV. — Typhus  Fever  complicated  with  Jaundice. 

Henry  B ,   aged   42,   admitted    into    London  Fever    Hospital 

Sept.  24,  18G2.  He  was  in  a  state  of  delirium  and  stupor  and  quite 
unable  to  give  any  account  of  himself,  but  his  body  was  covered  with 
a  petechial  typhus-eruption,  tongue  was  dry  and  brown,  and  pulse 
120  and  feeble.  There  was  also  well-marked  general  jaundice  of  skin 
and  conjunctivas,  with  bile-pigment  and  albumen  in  urine.  Abdomen 
distended  and  tympanitic,  but  no  tenderness  nor  enlargement  of  liver. 
Bowels  rather  loose  and  motions  dark.  Treatment  consisted  in  nitro- 
muriatic  acid,  nitrous  ether  and  taraxacum,  beef-tea,  milk,  wine,  and 
subsequently  brandy. 

The  jaundice  increased,  and,  although  pulse  fell  to  84,  patient 
became  weaker,  urine  had  to  be  drawn  off  by  catheter,  and  death  took 
place  on  Sept.  27. 

Autopsy. — Intestines  contained  bile,  and  there  was  no  obstruction 
of  bile-duct.  Liver  pale  and  slightly  fatty;  spleen  large  and  soft. 
Uriniferous  tubes  of  kidneys  gorged  with  granular  epithelium. 

Case  CXXXV. — Typhus  Fever — Douhle  Pleuro-pneumonia — Jaundice — 

Tyrosin  in  Urine. 

James  P ,  aged  47,  was  admitted  into  London  Fever  Hospital 

on  Feb.  23,  1864,  with  usual  symptoms  of  a  severe  attack  of 
typhus  fever,  duration  of  which  was  doubtful.  On  admission,  pulse 
128  and  feeble;  distinct  typhus-eruption;  tongue  diy  and  brown; 
bowels  confined ;  mind  confused  and  occasional  delirium  ;  signs  of 
congestion  at  bases  of  both  lungs.  He  was  ordered  mineral  acids 
with  ether,  6  oz.  of  brandy  ;  milk,  beef -tea,  and  an  egg ;  and  mustard 
and  linseed  poultices  to  back  of  chest. 

On  Feb.  26  patient  had  tremors  and  subsultus  and  was  lower ; 
a  decided  yellowness  of  skin  and  conjunctivae  was  noticed,  but  there 
was  no  enlargement  nor  tenderness  of  liver.  Respirations  easy,  and 
lungs  resonant  on  percussion.  Urine  threw  down  a  copious  deposit  of 
lithates  both  on  Feb.  26  and  27  ;  and  on  latter  day  respirations  40  ; 
dulness  with  tubular  breathing  over  lower  third  of  both  lungs  ;  and 
jaundice  was  more  decided.  Patient  was  ordered  a  mixture  of 
ammonia,  ether  and  senega,  and  brandy  was  increased  to  10  oz.. 

On  Feb.  28,  pulse  128  and  respirations  40  ;  dulness  of  lungs  had 
extended.  Jaundice  well  marked,  but  plenty  of  bile  in  motions. 
Urine  was  coloured  with  bile  and  gave  a  distinct  reaction  of  bile-pig- 
ment with  nitric  acid,  but  contained  no  bile-acids  (by  Harley's  test)  ; 
specific  gravity  1018  ;  a  moderate  amount  of  albumen  (about  ^).  On 
evaporating  it  down  to  a  syrup,  there  were  found  numerous  crystals 
of  triple  phosphate  and  yellowish-brown  crystalline  globules  of 
tyrosin. 

E  E 


41 8  JAUNDICE,  LECT.  XI. 

On  Feb.  29  the  pulse  140  ;  respirations  60  ;  rash  fading,  but  body 
covered  with  profuse  perspiration.  He  died  at  8  p.m.,  on  what  was 
probably  about  fourteenth  day  of  illness. 

Autopsy. — Jaundiced  tint  of  skin  and  conjunctivae  well  marked. 
Bile  in  duodenum ;  bile-ducts  quite  pervious.  Liver  not  at  all  con- 
gested, but  pale,  soft,  and  very  friable  ;  lobules  distinct,  but  secreting 
cells  in  their  pale  rims  were  loaded  with  oil.  Spleen  large  and 
diffluent.  Kidneys  appeared  normal,  except  that  cortices  were  pale 
and  epithelium  cells  opaque  and  granular.  No  leucin  nor  tyrosin  could 
be  detected  in  hepatic  tissue,  nor  in  kidneys.  Lower  lobes  and  lower 
part  of  upper  lobes  of  both  lungs  were  in  a  state  of  grey  granular 
consolidation,  and  pleural  surfaces  of  inflamed  lungs  were  coated  with 
a  thin  film  of  recent  lymph. 

In  the  last  case  the  double  pneumonia  no  doubt  contributed 
to  the  development  of  the  jaundice.  In  the  one  which  follows 
the  jaundice  was  a  sequel  of  typhus,  and  coexisted  with  phleg- 
masia dolens  and  fatty  degeneration  of  the  liver,  kidneys,  and 
heart. 


Case  CXXXVI. — Typhus  Fever,  folloived  hy  Phlegmasia  Dolens, 
Jaundice,  and  Death. 

Rosetta  J ,  aged  42,   admitted  into  London  Fever  Hospital 

Feb.  24,  1857.  This  patient  had  been  ill  for  about  eight  or  nine 
days  before  admission  ;  and  after  she  came  under  observation  in  hos- 
pital most  prominent  symptoms  were  :  pulse  120  ;  extreme  prostration  ; 
great  restlessness  and  much  low  muttering  delirium ;  involuntary 
stools  and  urine ;  well-marked  typhus-rash  ;  dry,  brown  tongue,  and 
constipated  bowels.  Treatment  consisted  in  wine,  carbonate  of 
ammonia,  and  castor  oil  to  keep  bowels  open. 

About  five  or  six  days  after  admission  an  improvement  took  place 
in  symptoms ;  and,  by  March  6,  she  had  regained  strength  to  a  con- 
siderable degree,  appetite  was  good,  and  pulse  80. 

On  March  9,  which  was  about  2'>rd  day  fi'om  first  commencement 
of  fever  and  the  Bth  of  convalescence,  patient  felt  ill  again.  Pulse 
120  and  small.  Complained  much  of  shooting  pains  in  left  leg.  Skin 
hot  and  diy.  Some  flushing  of  face.  Tongue  moist  and  very  red. 
The  next  day  considerable  swelling  and  some  tenderness  of  left  leg 
and  thigh,  but  no  hardness  in  cour.se  of  femoral  vein.  Heart's  action 
heaving  and  tumultuous,  but  no  bellows-murmur.  Breathing  short 
and  rapid  ;  no  cerebral  symptoms.  Blister  over  heart.  Wine  ^vi. 
Saline  efferv.  mixture  with  tinct.  hyoscy.  5s8  every  four  hours.  Left 
leg  to  be  fomented  and  kept  elevated. 

No  improvemont  took  place,  but  at  4  A.M.  of  March  12  (fourth  day 
from  first  complaint  of    pains  in   leg)  patient  felt  cold   and  chilly. 


LECT.  XI.  WITHOUT    OBSTRUCTION    OF    BILE-DUCT.  419 

There  was  a  great  increase  of  prostration  and  pulse  was  imperceptible, 
although  heart's  action  continued  tumultuous  as  before.  Breathing 
very  rapid.  Mental  faculties  unimpaired.  Skin  and  conjunctivae  of  a 
marked  yellow  tint,  and  face  livid.  Profuse  sweating.  No  tenderness 
over  liver,  nor  obvious  increase  of  hepatic  dulness.  Brandy  and  wine 
were  freely  administered,  but  patient  gradually  sank  and  died  towards 
evening. 

Autopsy. — Cadaveric  rigidity  well-marked.  Distinct  yellow  tinge 
of  skin  on  scalp,  neck,  and  ti'unk.  Thick  layer  of  subcutaneous  fat 
over  chest  and  abdomen.  Copious  sudamina  over  chest.  Left  leg 
swollen.  Left  ankle  8f  in.  in  circumference  ;  right,  8^  ;  left  calf,  13  in. ; 
right,  11^  ;  left  thigh,  17  in.  ;  right,  14|-.  Cerebral  membranes  mode- 
rately congested  and  separated  readily  from  brain.  Sub-arachnoid 
fluid  and  fluid  in  ventricles  of  a  decided  yellow  tint.  Substance  of 
brain  tolerably  firm ;  red  points  numerous.  Half  an  ounce  of 
yellow  serum  in  pericardial  sac.  Heart  8|  oz.  ;  valves  normal ;  left 
cavities  empty,  and  right  almost  empty.  "Walls  of  right  ventricle  very 
thin,  and  at  apex  composed  almost  entirely  of  fat.  Substance  of  heart 
pale  and  soft,  and  on  microscopic  examination  transverse  striation 
indistinct  and  fibres  presented  a  granular  aspect.  Left  femoral  and 
iliac  veins  healthy  and  contained  no  adherent  clot.  Each  of  lungs 
weighed  25  oz. ;  left  adherent  throughout  and  very  emphysema- 
tous ;  lower  lobes  of  both  lungs  much  congested ;  no  consolidation. 
Stomach  and  intestines  healthy.  Liver  52  oz.  ;  capsule  separated 
readily  ;  substance  of  organ  pale  and  very  soft  and  friable,  so  that  it 
broke  down  on  removal;  all  trace  of  lobules  had  disappeared,  cut 
surface  presenting  a  marrow-coloured  pulpy  appearance.  On  micro- 
scopic examination,  many  of  secreting  cells  could  be  seen  loaded  with 
oil ;  others  appeared  to  be  breaking  up  and  disintegrating,  and  much 
free  oil  and  granular  matter,  A  small  quantity  of  thick  bile  in  gall- 
bladder ;  bile-ducts  quite  pervious.  Spleen  13  oz.,  soft  and  pulpr. 
Kidneys  enlarged  ;  left  7^  oz.,  right  7  oz. ;  capsules  separated  readiJv  : 
outer  surface  smooth  ;  substance  pale  and  flabby  ;  cortical  substance 
pale  and  granular  and  rather  increased  in  amount ;  uriniferous  tubes 
gorged  with  oily  epithelium. 

The  following'  are  three  of  the  four  instances  of  enteric 
fever  complicated  with  jaundice  which  I  have  met  with.  In 
the  first  the  jaundice  occurred  during  a  relapse  of  the  fever, 
and  was  probably  catarrhal;  in  the  second  it  came  on  durijig 
the  acme  of  the  fever  and  persisted  duiing  convalescence ;  in 
the  third  it  coexisted  with  thrombosis  of  the  femoral  vein  and 
albuminuria. 


420  JAUNDICE,  tECT.  xi. 

Case  CXXXVII. — Enteric  Fever  followed  by  a  Relapse,  witlt  Jmindice. 

Mary  A.  C ,  aged  43,  was  admitted  into  London  Fever  Hos- 
pital suffering'  from  enteric  fever  on  Feb.  9,  1863.  She  had  a 
dry,  red,  fissured  tongue,  with  diarrhoea  and  rose-spots.  She  had  been 
ill  for  nine  days  before  admission,  and  on  Feb.  25  she  began  to  con- 
valesce. She  improved  daily  until  March  5,  when  febrile  symptoms 
and  diarrhoea  returned,  and  on  March  8  fresh  rose-spots  were  observed. 
On  March  11  conjunctivaj  and  skin  first  became  yellow,  and  on  March 
14  there  was  deep  jaundice  of  whole  surface.  Urine  was  dai'k  green, 
deposited  much  lithates,  and  contained  much  bile-pigment,  but  no 
albumen,  leucin,  nor  tyrosin.  The  bowels,  from  appearance  of  jaundice, 
were  rather  confined,  and  motions  clay-coloured.  Hepatic  dulness 
measured  4  in.  in  right  mammary  line ;  no  tenderness  below  right 
ribs.  Tongue  dry  ;  great  prostration  ;  but  no  delirium.  Patient  was 
treated  with  nitro-muriatic  acid  and  gentian,  and  linseed-poultices 
over  abdomen.  On  March  IG  jaundice  began  to  subside,  and  by  21st 
it  had  almost  disappeared  and  patient  was  again  convalescent. 

The  following  case  was  communicated  to  me  in  a  letter 
from  the  patient,  who  is  a  Fellow  of  the  Eojal  College  of 
Physicians. 

Case  CXXXVIII.—-B» ^er/c  Fever  comj)licat€d  with  Jaundice. 

One  remark  struck  me  in  your  book  on  Fevers.  You  refer  to  the 
extreme  rarity  of  the  complication  of  jaundice  with  typhoid.  I  myself 
was  the  subject  of  this  affection  in  a  very  intense  degree.  This  was  in 
Paris  in  1842,  The  jaundice  came  on  suddenly  about  the  acme  of  the 
fever.  When  the  event  was  told  to  Rostan,  who  was  seeing  me,  he 
said  it  was  a  '  complication  bien  facheuse,'  and  he  did  not  expect  that 
I  would  recover.  This  deep  jaundice  persisted  for  some  time,  even 
during  convalescence,  so  that  when  I  used  to  crawl  into  the  Luxem- 
bourg Gardens  I  was  Tcnown  amongst  the  frequenters  as  the  '  Monsieur 
Jaune.' 

Case  CXXXIX. — Evteric  Fever  complicated  ivith  Jaundice  and 
Thrombosis  of  Femoral  Vein. 

On   Dec.   12,    1863,    I   was  requested  by   Mr.    Edward   Newton 

to  see  Mr.  W ,  a  gentleman  about   54  years  of   age,  who  on   Sept. 

30  had  been  taken  ill  with  enteric  fever,  which  presented  the 
usual  symptoms  of  diarrlura,  roso-spots,  &c.  till  fourteenth  day,  when 
he  Ijt'canie  jaundiced  and  albumen  appeared  in  urine.  During  con- 
valescence he  got  thrombosis  of  left  femoral  vein,  with  considerable 
tenderness  along  the  vein  ;  but  after  ten  days  this  subsided  and  the 
albumen  disappeared  from  urine.     About  a  week  before  I  saw  him,  he 


LECT.  XI.  WITHOUT   OBSTBUCTION   OF    BILE-DUCT.  421 

bad  driven  out  to  country,  got  out  of  the  carriage  and  walked  for  five 
minutes.  Within  a  few  hours  pain  and  swelling  in  leg  returned,  and 
when  I  saw  him  on  Dec.  12  there  was  considerable  pitting  of  left 
leg,  but  only  slight  tenderness  along  vein.  Urine  was  turbid  ;  sp. 
gr.  1013  ;  it  contained  one-eighth  of  albumen  and  gTanular  epithe- 
lial casts,  but  only  a  faint  trace  of  bile-pigment,  and  no  leucin  nor 
tyrosin.  Impulse  of  heart  barely  perceptible,  and  first  sound  short 
and  abrupt  like  second. 

The  patient  was  treated  with  iron,  quinine,  a  generous  diet,  and 
wine.  At  first  he  rallied  somewhat,  and  on  Jan.  9  swelling  had 
almost  left  legs,  there  was  no  jaundice,  and  only  a  trace  of  albumen 
in  urine  ;  but  soon  after  this  he  became  weaker,  and  he  died  at  St. 
Leonards  in  March  1864.     There  was  no  post-mortem  examination. 

In  the  four  cases  which  follow,  jaundice  appeared  in  the 
course  of  scarlet  fever.  In  the  first  three,  two  of  which 
were  fatal,  the  symptoms  indicated  serious  blood-changes;  in 
the  fourth  the  jaundice  was  probably  the  result  of  simple  con- 
gestion. 

Case  CXL. — Scarlatina — Jaundice — Death  by  Coma. 

Samuel  W ,  aged  27,  was  admitted  into  London  Fever  Hospital 

on  March  6,  1863,  having  been  ill  with  fever  and  sore  throat  for  four 
or  five  days.  On  admission,  pulse  120,  weak.  Copious,  bright, 
punctated,  scarlet  eruption.  Skin,  especially  of  face,  and  conjunctivae 
distinctly  jaundiced.  Tongue  very  red  at  edges,  dry  and  brown  along 
centre  ;  throat  sore  ;  tonsils  red  and  enlarged,  not  ulcerated ;  occa- 
sional hiccough  ;  had  vomiting  and  some  purging  before  admission  ;  no 
nasal  discharge  ;  mind  clear.  Ordered :  carbonate  of  ammonia  and 
chlorate  of  potash,  5  gr.  of  each  every  four  hours.  Wine  6  oz. ;  beef- 
tea  and  milk. 

During  night  patient  became  quite  unconscious  and  face  was 
dusky  and  livid,  and  on  following  morning  at  8.30  A.M.  he  died. 

Autojpstj. — Skin  and  white  tissues  deeply  jaundiced.  Bile-ducts 
patent.  Liver  presented  a  niitmeg  appearance  on  section,  margins  of 
lobnles  being  pale  and  their  central  vessels  containing  blood ;  oily 
matter  in  secreting  cells  much  increased.  Kidneys  large,  right 
weighing  6|  oz.  and  left  8^  oz. ;  capsules  non-adherent  and  surfaces 
smooth ;  cortices  hypertrophied,  five  or  six  lines  in  thickness,  dark-red 
and  dripping  with  blood  ;  uriniferous  tubes  gorged  with  finely  granular 
epithelium.  Urine  from  bladder  had  a  specific  gravity  of  1015,  and 
contained  a  considerable  amount  of  albumen  and  bile-pigment. 

Case  CXLI. — Scarlatina — Jaundice — Sudden  Death. 

Alfred  C ,  aged  19,  was    admitted  into  London  Fever  Hospital 

on  Dec,  4,    1862.       His  illness   had    commenced  four    days   before 


422  JAUNDICE,  lect.  xi. 

with  pains  in  limbs  and  sore  throat,  folio-wed  by  a  scarlet  rash  which 
was  now  well  ont.  Pulse  130  ;  tongue  moist,  with  white  coat  and  red 
edges;  bowels  open  ;  tonsils  swollen  and  red,  not  ulcerated;  no  nasal 
discharge.  Ordered,  quinine  (2  gr.  every  four  hours),  milk  and 
beef-tea. 

Dec.  5  (6th  da}'). — Pulse  136  and  feeble.  Had  a  restless  night, 
wandering  occasionally,  but  slept  at  intervals.  Swallows  liquids  well. 
Rash  still  out.     Bowels  open.     Ordered  4  oz.  of  -wine. 

Dec.  6  (7th  day). — Was  restless  during  night,  but  slept  at 
intervals.  This  morning  nurse  observed  lips  to  be  slightly  livid  and 
face  and  conjunctivje  yellow,  but  otherwise  man  seemed  no  worse.  He 
asked  nurse  to  put  his  tea  down  as  it  was  too  hot.  Ten  iniuutes  later 
nurse  saw  him  again  and  found  him  unconscious,  breathing  quickly, 
and  he  died  in  five  minutes,  at  8.30  a.m. 

Autopsr/. — All  white  tissues  were  tinged  yellow,  and  lungs  were 
moderately  congested  posteriorly.  Liver  and  bile-ducts  presented 
nothing  abnormal,  except  that  former  was  pale  and  slightly  fatty. 
Kidneys  considerably  congested ;  uriniferous  tubes  gorged  with 
granular  epithelium  ;  urine  in  bladder  contained  a  small  quantity  of 
albumen. 

Case  CXLII. — Scarlatina — Jaundice — Recovery. 

Emily  S ,  aged  18,  was  admitted  into  Fever  Hospital  April  5, 

1864,  having  been  ill  one  day  with  fever  and  sore  throat.  On  admis- 
sion, pulse  120  ;  skin  very  hot ;  punctated  scarlet  rash  of  good  colour 
and  moderate  intensity.  Tongue  red,  with  white  fur,  and  dry  along 
centre  ;  fauces  red  ;  tonsils  large ;  no  ulcer.  No  enlargement  of 
glands  in  neck.  Ordered  a  mixture  with  chlorate  of  potash  and  free 
chlorine,  beef-tea,  &c. 

April  6  (3rd  day). — Pulse  120,  feeble.  Bowels  open  three  or  four 
times  since  last  night.     Ordered  four  ounces  of  wine  and  an  e^Q. 

April  7. — During  early  part  of  last  night  was  very  restless  and 
wandered,  but  slept  fairly  after  an  opiate  draught.  To-day,  pulse  130 ; 
tongue  dry ;  no  ulcer  of  tonsils  :  answers  correctly ;  intense  scarlet 
rash  on  arms. 

Aprils  (6th  day). —  Pulse  120,  very  feeble  ;  rash  fading;  entire 
skin  and  conjnnctiv83  present  alight  jaundiced  tint;  no  tenderness 
over  liver  ;  bowels  open  twice ;  motions  pale  yellow  ;  tongue  dry ; 
desquamation  commencing  on  face  ;  slept  badly,  and  mind  wanders  at 
times.  Urine  contains  bile-pigment,  but  no  albumen.  Ordered  6  oz. 
of  brandy. 

Apjril  11. — Pulse  96  ;  skin  cooler  ;  desquamation  general ;  jaundice 
as  before  ;  three  light-yellow  stools  ;  mind  clearer ;  appetite  returning, 
and  girl  feels  better.     Ordered  quinine  and  custard  pudding. 

April  13. — Copious  desquamation.     Jaundice  fading. 


LECT.  XI.  WITHOUT    OBSTRUCTION   OF    BILE-DUCT.  423 

April  17  (14th  day). — General  health  improving.  To-day,  for 
first  time,  skin  is  free  from  yellow  tint.  Bowels  still  slightly 
relaxed. 

Was  discharged  well  on  April  29. 

Case  CXLIII. — Scarlatina — Jaundice — Eecovery. 

Frederick  C ,  aged  27,  was  admitted  into  London  Fever  Hosp. 

Dec.  17,  1861.  Wife  and  child  in  hospital  with  well  marked  scar- 
latina. Was  taken  ill  day  before  with  sore  throat,  rigors,  and  head- 
ache ;  and  on  admission,  pulse  114  ;  faint  scarlet  rash;  tongue  moist 
and  furred,  red  at  tip  and  edges ;  swallows  with  pain  ;  tonsils  large 
and  red,  but  not  ulcerated ;  bowels  open.  Was  ordered  an  acid 
mixture,  low  diet,  and  beef -tea. 

Dec.  19  (4th  day). — Face  somewht  yellow;  some  tenderness  over 
liver.     Ordered  two  aperient  pills. 

Dec.  20. — Jaundice  more  decided ;  conjunctiva  yellow  ;  tongue 
moist,  clean  and  red  ;  throat  less  sore ;  bowels  open  three  times ; 
plenty  of  bile  in  motions  ;  rash  gone  ;  pulse  84 ;  and  feels  better. 

Dec.  21  (6th  day). — Jaundice  more  intense  ;  urine  contains  much 
bile-pigment,  but  no  albumen ;  slight  tenderness  on  pressure  ovei^ 
liver ;  bowels  confined.  Ordered  a  mixture  containing  nitrate  of 
potash  and  sulphate  of  magnesia. 

Dpc.  23. — Pulse  66  ;  less  jaundice  ;  no  pain  in  hepatic  region  ; 
bowels  open  several  times. 

From  this  date  patient  continued  to  improve  until  discharge  on 
Jan.  26,  1862.  The  jaundice  disappeared  in  a  few  days.  Desquama- 
tion was  slight. 

I  have  already  brouglit  under  your  notice  several  cases 
"wliere  jaundice  resulted  from  pysemia  and  where  multiple 
abscesses  were  found  in  the  liver  (Cases  LXVII.  to  LXXIII. 
p.  169).  In  the  following  case  the  jaundice  was  also  due  to 
pysemia,  but  there  were  no  purulent  deposits  in  the  liver,  and 
at  the  same  time  the  bile-ducts  were  perfectly  patent. 

Case  CXLIV. — Acute  Necrosis  of  Cervical  Vertehrce — Pycemia — 

Jaundice. 

Elizabeth  A ,  aged   24,  admitted  into  London  Fever  Hosp.  on 

Feb.  17,  1868.  She  had  been  on  the  streets  prior  to  her  marriage 
and  had  scars  of  buboes  in  groins.  Twelve  days  before  admission  she 
had  been  suddenly  seized  with  acute  pain  in  back  of  neck,  which  had 
never  left  her,  had  prevented  all  motion  of  her  head,  and  was  accom- 
panied by  vomiting.  She  fancied  that  she  had  injured  her  neck  while 
wrestling  a  week  before  her  seizure,  bat  her  friends  attached  no  im- 
portance to  this  as  a  cause  of  her  illness. 


424  JAUNDICE,  iJiCT.  XI, 

On  admission,  patient  was  suffering  from  symptoms  of  general 
fever,  without  any  indication  of  local  disease  excepting  great  pain  and 
tenderness  in  back  of  neck  and  in  both  shoulders,  increased  by  move- 
ment, but  without  any  obvious  swelling  or  induration.  Pulse  108 ; 
tongue  moist  and  red.  Mind  clear.  No  eruption  on  skin,  which  was 
hot,  with  occasional  perspirations ;  no  rigors.  A  blister  was  applied 
to  back  of  neck,  and  a  mixture  containing  iodide  of  potassium  and 
carbonate  of  ammonia  (aa  gr.  iv)  and  extract  of  belladonna  (gr.  ^) 
was  pi-escribed. 

A  few  days  after  admission  an  obscure  swelling  could  be  felt  down 
neck  on  either  side  of  cervical  vertebrae  ;  there  Avas  a  circumscribed 
pink  flush  on  left  cheek  ;  tongue  dry  and  brown  down  centre  ;  and 
patient  complained  of  great  burning  and  dryness  of  throat.  Still 
occasional  vomiting,  and  pulse  had  risen  to  126.  On  Feb.  28  patient 
had  several  severe  rigors  ;  she  had  been  slightly  delirious  in  night ; 
diarrhoea  with  copious  watery  motions  ;  a  distinct  pericardial  friction 
over  heart,  but  no  albumen  in  urine.  On  March  2  there  was  slight, 
but  distinct,  jaundice  of  skin  and  conjunctivae  and  bile-pigment  in 
urine,  but  there  was  no  enlargement  nor  tenderness  of  liver,  and 
motions,  which  were  still  watery,  contained  plenty  of  bile  ;  pulse  144; 
no  return  of  rigors  and  no  perspirations.  A  fluctuating  swelling,  size 
of  a  small  orange,  was  discovered  a  little  behind  left  ear,  which  on 
March  4  was  opened  and  discharged  a  quantity  of  thick  pus.  Patient 
was  extremely  prostrate,  scarcely  conscious,  and  very  restless.  Jaun- 
dice increased  in  intensity  until  death  on  March  5. 

Autopsy. — Lamina3  of  all  cervical  vertebrae  excepting  first  and  two 
last  bare  and  bathed  in  pus  ;  also  pus  in  spinal  canal  external  to  theca 
and  in  left  lateral  sinus.  Left  lung  contained  five  or  six  small  patches 
of  lobular  pneumonia  passing  into  pus.  Liver  seemed  healthy,  except 
that  secreting  cells  contained  too  much  oil ;  it  was  not  congested,  and 
bile-ducts  were  perfectly  patent.     No  ulceration  of  the  intestines. 

Case  CXLV.  is  an  example  of  jaundice  occurring  in  the 
course  of  acute  pleuro-pneuraonia. 

Case  CXLV. — Acute  JPleuro-'pneumonia  complicated  tvith  Jaundice. 

On  May  23,  1867,  I  was  requested  by  Dr.  W.  H.  Cook,  of  Hamp- 
stoad,  to  see  a  clergyman,  between  ^0  and  60  years  of  age,  of  spare 
build  and  temperate  habits,  who  had  been  long  .subject  to  spasmodic 
asthma,  and  who,  five  days  before,  had  been  seized  with  severe  pain  in 
right  hypochondrium  and  febrile  symptoms,  followed  by  slight  jaun- 
dice, cough,  and  high-coloured  urine.  On  examination  we  discovered 
all  the  physical  signs  of  jjleuro-pneumonia  of  lower  half  of  right  lung — 
dulness,  tubular  breathing,  fine  crepitation,  friction,  and  increased 
vocal  resonance.  There  were  also  cough  with  considerable  dyspnoea 
and  tenacious  rusty  sputa,  and  acute  pain  in  right  side,  greatly  aggra- 


5LECT.  XT.  WITHOUT    OBSTRUCTION    OP   BILE-DUCT.  425 

vated  by  coughing  or  by  taking  a  long  inspiration.  Pulse  120  ;  respi- 
rations 36.  Along  with  these  signs  of  pulmonary  disease  there  was 
Bligbt  but  decided  jaundice  of  skin  and  conjunctivae,  and  urine  gave 
evidence  of  presence  of  bile-pigment.  Liver  projected  about  half  an 
inch,  below  ribs  in  right  mammary  line ;  slight  tenderness  over  it  on. 
firm  pressure  ;  no  deficiency  of  bile  in  motions.  Tongue  dry  and 
brown.  Great  despondency  as  to  result  of  his  illness.  Patient  was 
treated  with  carbonate  of  ammonia,  nitrous  ether,  stimulants,  opiates, 
and  other  anodynes  to  relieve  pain  and  procure  sleep,  and  mustard  and 
linseed  poultices  to  side. 

At  first  there  was  a  marked  improvement  in  both  physical  signs 
and  general  symptoms,  but  early  in  June  pleurisy  and  then  pneu- 
monia made  their  appearance  in  left  lung,  and  patient  continued  to 
sink  until  death  on  June  14.  To  the  last  there  was  a  slight  icteroid 
tinge  of  skin  and  conjunctivse,  but  motions  always  contained  plenty  of 
bile.     There  was  no  post-mortem  examination. 

Case  CXLVI.  appears  to  be  a  well-marked  instance  of 
jaundice  from  congestion  of  the  liver.  The  fact  of  the  jaundice 
following  an  attack  of  acute  rheumatism,  from  Dr.  Graves's 
observations  (see  antea,  p.  818),  led  us  to  look  for  urticaria,  but 
no  such  eruption  appeared. 

Case  CXLVI. — Jaundice  from  Congestion  of  Liver. 

Jane  Gr ,  aged  30,  was   admitted  into  Middlesex  Hospital   on 

April  2,  1868.  You  will  remember  her  as  a  patient  in  Seymour  Ward 
from  January  28  to  March  9,  sufiering  from  acute  rheumatism  and 
pericarditis.  After  leaving  hospital  she  had  coaiplaiued  of  weakness 
and  rheumatic  pains,  but  she  had  been  gradually  getting  better  until 
March  26,  when  she  was  attacked  with  pain  in  region  of  liver,  back 
and  front,  which  on  March  28  became  much  worse  and  was  followed 
on  next  day  by  nausea,  vomiting,  and  great  flatulence,  and  on  30th  by 
jaundice.  Vomiting  only  lasted  for  a  day,  but  jaundice  and  pain 
continued  to  increase. 

On  admission  v? ell-marked  jaundice  of  entire  skin  and  conjunctivae, 
and  patient  complained  greatly  of  pain  in  epigastrium  and  right  hy- 
pochondrium,  stretching  up  to  right  shoulder  and  down  back.  Pain 
was  greatly  increased  by  pressure  below  right  ribs  and  also  by  lying 
on  left  side,  which  patient  said  always  took  away  her  breath.  Area  of 
hepatic  dulness  was  increased,  in  r.  m.  1.  measuring  5^  in.  and  extend- 
ing quite  an  inch  beyond  margin  of  ribs.  Urine  was  acid  and  dark, 
and  contained  a  considerable  amount  of  bile-pigment.  Tongue  furred ; 
no  appetite  ;  bowels  had  been  very  freely  moved  by  a  dose  of  compound 
jalap  powder  taken  on  day  before  admission,  and  motions  had  con- 
tained plenty  of  bile.     Pulse  96  and  temperature  100°. 


4^6  JAUNDICE.  LKCT.  XI. 

The  wliole  hepatic  region  was  dry-cupped  and  afterwards  covered 
by  linseed-poultices  ;  a  draught  of  sulphate  of  magnesia  and  senna  was 
ordered,  with  a  diuretic  mixture  containing  bitartrate  of  potash  and 
nitrous  ether.     Diet  was  restricted  to  milk  and  beef-tea. 

On  following  morning  catamenia  appeared  for  first  time  since 
patient's  confinement  four  months  before ;  frequent  bilious  motions  ; 
pain  and  tenderness  in  region  of  liver  greatly  relieved. 

On  April  8  patient  was  free  from  pain  and  jaundice  scarcely  per- 
ceptible. A  mixture  with  nitric  acid  and  gentian  was  now  prescribed 
and  fish  diet. 

On  April  13  jaundice  quite  gone  ;  hepatic  dulness  in  r.  m.  1.  only 
4  in.  ;  no  tenderness  below  right  libs.  On  following  day  patient  was 
discharged. 

The  last  case  wliicli  I  shall  mention  is  remarkable  not  only 
for  the  persistence,  but  for  the  hereditary  character  of  the 
jaundice.  Although  there  may  be  doubts  as  to  whether  the 
yellowness  of  the  children  of  the  third  generation  was  true 
jaundice,  there  can  be  no  question  as  to  its  reality  in  the  case 
of  the  mother  and  her  two  sons.  It  must  be  admitted  that 
the  pathology  of  the  jaundice  in  these  cases  is  obscure.  It  is 
clear  that  there  is  little  or  no  obstruction  of  the  bile-duct ; 
and  the  most  probable  view  is  that  the  liver  either  secretes  an 
excess  of  bile,  or  is  in  a  permanent  state  of  congestion  (see  p. 
412).  But  whatever  be  its  pathology,  its  intimate  relation  to 
gout  is  interesting  in  relation  to  the  view  which  I  shall  here- 
after submit  to  your  notice,  that  gout  has  its  origin  in  func- 
tional derangement  of  the  liver. 

Case  CXLVII. — Hereditary  Jaundice  and  Gout. 

On  Feb.  18,  1875,  I  had,  through  the  kindness  of  Dr.  Moxon,  an 
opportunity  of  seeing  the  following  case. 

Robert  J ,  aged  30,  says  he  was  born  yellow  and  that  he  has 

been  jaundiced  as  long  as  he  can  remember.  He  had  never  been 
robust,  but  from  age  of  17  to  27  he  had  been  in  habit  of  walking  twenty 
miles  a  day,  exposed  to  all  kinds  of  weather  and  eating  all  sorts  of  food. 
At  21  he  had  been  laid  up  for  six  weeks  with  a  febrile  attack  ;  and  at  27 
he  had  another  illness,  after  which  he  had  led  a  more  sedentary  life,  but 
had  continued  to  drink  about  three  ))ints  of  beer  daily.  From  27  up  to 
the  date  of  his  visit  to  me  he  hud  suffered  much  from  gout  in  fingers  and 
toes,  which  had  always  been  relieved  by  iodide  of  potassium.  Urine 
had  deposited  a  copious  sediment  as  long  as  he  could  remember.  Four 
months  before  seeing  me  he  had  left  ofl"  beer  and  all  stimulants,  and 
during  that  time  he  had  become  much  fairer  than  ever  before. 

I  made  following  notes  :  Body  fairly  nourished,  and  is  leading  an 


LECT.  XI.  DIAGNOSIS    OP   CAUSES.  42/ 

active  life.  Has  decided  yellowness  of  skin  and  conjunctivae.  Urine 
contains  abundance  of  lithates,  and  presents  distinct  reaction  of  bile- 
pigment.  Liver  slightly  enlarged,  measuring  4|  in.  in  r.  m.  1.,  not 
tender.  Appetite  good ;  occasional  flatulence  ;  bow^els  sluggish ; 
motions  fairly  coloured  with  bile.  Always  has  giddiness  on  looking  up, 
and  formerly  had  it  whenever  he  got  up  or  lay  down. 

On  Oct.  9,  1876,  Dr.  Moxon  wrote  to  me  as  follows  :  R.  J.  is  still 
a  teetotaller ;  but  urine  contains  bile-pigment  as  before  and  jaundice 
persists. 

R.  J.  has  a  brother,  two  years  and  eight  months  older  than  him- 
self, who  has  also  been  deeply  jaundiced  all  his  life  and  in  Feb.  1875 
was  laid  up  with  gout.  In  October  1876  I  heard  from  Dr.  Moxon  that 
this  brother  continued  to  drink  beer  and  was  still  very  much  jaundiced. 

The  mother  of  these  two  brothers  died  at  age  of  54.  She  had  been 
in  habit  of  drinking  malt  liquor  freely,  and  for  fourteen  years  before 
death  she  had  been  a  great  sufferer  from  gout,  her  feet  and  every  one 
of  her  finger-joints  being  greatly  deformed  from  it.  During  same 
period  she  had  been  continuously  jaundiced,  the  '  whites  'of  her  eyes 
being  deep  yellow,  and  she  had  had  frequent  bilious  attacks.  She 
had  borne  seven  children,  but  five  had  died  soon  after  birth,  or  in  early 
infancy.  An  only  brother  had  died  of  consumption ;  but  her  father 
had  suffered  greatly  from  gout  and  liver-complaints. 

Father  of  R.  J.  is  still  (Oct.  1876),  alive  and  healthy;  never  bad 
gout  nor  jaundice. 

I  learn  from  Dr.  Moxon  also  that  both  R.  J.  and  his  brother  have 
had  several  children,  all  of  whom  '  became  deeply  jaundiced  two  days 
after  birth,  the  colour  being — eyes,  body,  and  whole  frame — as  deep 
as  possible,  but  disappearing  after  about  a  month.' 

Before  concluding  this  lecture  I  must  say  a  fev^  words  on 
the  diagnosis  of  the  causes  of  jaundice,  and  more  especially  on 
the  detection  of  bile-acids  in  the  urine  as  an  aid  to  diagnosis. 
In  1858  Kuhne  announced  that  '  in  jaundice  resulting  from 
closure  of  the  ductus  communis  choledochus,  the  urine  always 
contains  biliary  acid  as  well  as  bile-pigment ; '  but  that  under 
ordinary  circumstances,  when  the  ducts  are  free,  '  the  bile-acids 
for  the  most  part  pass  off  by  the  fseces  and  are  not  reabsorbed 
from  the  intestine.'  ^  Dr.  G.  Harlej,  in  his  Essay  on  Jaundice, 
published  in  1868,  adopting  the  view  that  bile-acids  are  formed 
by  the  liver,  while  bile-pigment  is  pre-formed  in  the  blood  (see 
antea,  p.  326),  maintained  that  the  detection  of  bile-acids  in 
the  urine  was  a  means  of  distinguishing  jaundice  due  to  ob- 
struction from  that  due  to  suppressed  secretion.     '  In  jaundice 

'  Virchow's  Archiv,  Sept.  1858  ;  and  Translator's  Preface  to  the  English  edition 
of  Frerichs  on  the  Liver,  vol.  i.  pp.  14,  15,  June  1860. 


428  JAUNDICE.  LECT.  XI. 

from  suppression/  Dr.  Harley  remarks,  '  the  liver  does  not 
secrete  bile  ;  consequently  no  bile-acids  being  formed,  none  can 
enter  the  circulation,  and  tliey  are  therefore  not  to  be  detected 
in  the  urine;'  whereas  in  jaundice  from  obstruction  'bile  is 
secreted  and  absorbed  into  the  blood,  and  the  bile-acids  not 
being  all  transformed  in  the  circulation  are  eliminated  by  the 
kidneys  and  appear  in  the  urine  '  (p.  60).  Accordingly,  it  is 
argued  that  the  presence  or  absence  of  bile-acids  in  the  urine, 
in  any  case  of  jaundice,  ought  to  decide  whether  this  be  due 
to  obstruction  or  suppression  ;  and  the  readiest  mode  by  which 
the  bile-acids  may  be  detected  is  said  to  be  the  following  ap- 
plication of  Pettenkofer's  test :  '  To  a  couple  of  drachms  of  the 
suspected  urine  add  a  small  fragment  of  loaf-sugar,  and  after- 
wards pour  slowly  into  the  test-tube  about  a  drachm  of  strong 
sulphuric  acid.  This  should  be  done  so  as  not  to  mix  the  two 
liquids.  If  biliary  acids  be  present,  there  will  be  observed  at 
the  line  of  contact  of  the  acid  and  urine — after  standing  for  a 
few  minutes — a  deej)  purple  hue.  This  result  may  be  taken  as 
a  sure  indication  that  the  jaundice  is  due  to  obstructed  bile- 
ducts.'  On  the  other  hand,  '  a  brown  instead  of  a  purple  tint ' 
is  said  to  be  equally  indicative  of  suppression  (p.  61) . 

If  the  views  here  announced  should  be  confirmed,  the 
pathology  of  jaundice  would  be  greatly  simplified  and  physio- 
logical chemistry  would  have  contributed  an  important  aid  to 
diagnosis.  But  after  having  bestowed  considerable  attention  on 
the  matter,  it  appears  to  me  that  both  the  theory  and  the  prac- 
tice based  on  it  are  open  to  objection. 

1.  For  reasons  already  given  (p.  327),  the  theory  that 
jaundice  independent  of  obstruction  of  the  bile-ducts  is  due 
to  suppressed  secretion  of  bile  is  itself  a  very  improbable  one. 

2.  Supposing  the  theory  to  be  correct,  bile-acids  might  be 
present  in  the  urine  unless  the  liver  were  entirely  destroyed  or 
the  secretion  wholly  suppressed — events  admitted  to  be  of  rare 
occurrence.  In  cases  also  of  obstruction  of  long  standing,  the 
secreting  tissue  of  the  liver,  as  Dr.  Harley  admits,  may  be 
destroyed,  and  accordingly  bile-acids  might  be  absent  from  the 
urine,  although  the  jaundice  resulted  in  the  first  instance 
from  obstruction.  In  point  of  fact,  Golowin  and  other  recent 
observers  have  found  that  in  cases  of  jaundice  from  obstruction 
the  bile-acids  ultimately  disappear  altogether.  It  follows  that, 
however  correct  the  theory,  its  practical  application  may  mis- 
lead the  physician  iu  diagnosing  the  cause  of  jaundice. 


LECT.  XI,  DIAGNOSIS   OP   CAUSES.  429 

3.  The  clinical  evidence  adduced  in  corroboration  of  the 
view  that  jaundice  from  obstruction  is  to  be  recognised  by 
the  presence  of  bile-acids  in  the  urine  is  as  yet  insufficient. 
Neither  Scherer,'  a  chemist  of  note,  nor  Frerichs  has  ever 
found  bile-acids  in  the  urine  in  any  form  of  jaundice ;  and 
although  minute  quantities  may  be  detected  by  delicate  tests 
such  as  that  of  Hoppe,  after  separating  the  urinary  pigments, 
the  necessity  of  which  Kuhne  admits,  these  methods  are 
scarcely  applicable  to  the  ordinary  purposes  of  diagnosis.  Of 
the  five  cases  of  jaundice  recorded  by  Dr.  Harley,^  in  which 
the  urine  was  tested  for  bile-acids,  one  was  a  case  of  jaundice 
from  obstruction  of  the  common  duct  where  abundant  bile- 
acids  were  discovered  on  one  occasion,  but  not  a  trace  of  them 
ten  days  afterwards  ;  although  seven  weeks  later,  shortly  before 
death,  they  reappeared  in  small  quantity  (p.  74).  Another  was 
a  case  of  acute  yellow  atrophy  of  the  liver,  in  which  a  decided 
reaction  of  bile-acids  in  the  urine  was  obtained.  This  discovery 
might  have  been  thought  fatal  to  the  diagnostic  significance 
attributed  to  bile-acids  in  the  urine,  inasmuch  as  in  acute 
yellow  atrophy  the  bile-ducts  are  perfectly  patent  and  the 
disease  has  usually  been  regarded  as  a  typical  illustration  of 
jaundice  from  suppression ;  but  Dr.  Harley  is  of  opinion  that 
the  presence  of  bile-acids  in  this  case  proves  that  in  acute 
atrophy  the  suppression  is  complicated  with  reabsorption  of 
bile  (pp.  33,  38). 

4.  Since  the  promulgation  of  Dr.  Harley's  views,  I  have 
tested  the  urine  in  a  large  number  of  cases  of  jaundice,  and 
have  serious  doubts  as  to  Dr.  Harley's  modification  of  Petten- 
kofer's  test,  in  which  there  is  no  provision  for  separating  in 
the  first  place  the  urinary  pigments,  being  a  reliable  indication 
of  the  presence  of  bile-acids  in  the  urine.^  You  will  remember 
that  on  one  occasion  I  applied  the  test  to  the  urine  of  six 
patients  under  my  care  in  the  Middlesex  Hospital.  In  three 
of  the  six  cases  a  dark  purple  colour  was  developed  at  the  line 
of  junction  of  the  sulphuric  acid  and  the  urine.  One  of  the 
three  cases  was  an  example  of  jaundice  from  impacted  o-all- 
stone  :  in  the  other  two  cases,  there  was  neither  jaundice,  nor 
any  symptom  of  disease  of  the  liver,  and  yet  when  the  three 

1  Cheminal  Gazette,  vol.  ii.  1845,  p.  208. 

2  Op.  cit.  pp.  27,  38,  74,  94,  111. 

'  Dr.  Hilton  Fagge  has  arrived  at  a  similar  conclusion.     Guy's  Hosp.  Eep.  1875. 

vol.  XX. 


430  JAUNDICE.  lECT.  XI. 

tftst-tubes  were  placed  side  by  side,  it  was  impossible  to  dis- 
tinguish the  colour  in  the  first  from  that  in  the  remaining 
two.  Other  obsei'vers,  I  believe,  have  arrived  at  similar  results. 
I  find  also  that  Neubauer,  in  his  excellent  monograph  on  the 
Urine,^  states  that  certain  of  the  pigments  of  the  urine  produce 
a  dark  purple-violet  colour  exactly  resembling  that  from  bile, 
when  a  large  quantity  of  strong  sulphuric  acid  is  added  to  the 
urine.  To  separate  the  urinary  pigments  before  testing  for 
the  bile-acids  would  obviously  be  too  tedious  and  difficult  a 
process  for  the  ordinary  purposes  of  diagnosis,  even  supposing 
that  the  presence  or  absence  of  the  bile-acids  threw  more  light 
on  the  cause  of  jaundice  than  it  probably  does. 

Although  from  these  considerations  I  regret  that  I  cannot 
recommend  the  test  to  which  I  have  been  adverting,  as  furnish- 
ing reliable  information  as  to  the  cause  of  jaundice,  the  subject 
is  one  which  you  Avill  do  well  to  investigate  for  yourselves. 
Meanwhile,  in  forming  a  diagnosis  you  will  sometimes  be 
assisted  by  bearing  in  mind  the  remarks  with  which  I  bring 
this  lecture  to  a  close 

1.  The  chief  indication  of  obstruction  of  the  common  bile- 
duct  is  furnished  by  the  stools.  When  there  is  no  obstruction 
of  the  duct,  the  stools  contain  bile ;  but  when  the  duct  is  ob- 
structed, no  bile  enters  the  bowel  and  the  stools  are  clay- 
coloured.  Several  sources  of  fallacy  must  be  remembered. 
First,  the  jaundice  usually  persists  for  a  short  time  after  the 
removal  of  the  obstruction,  and  thus,  as  happens  not  unfre- 
quently  in  the  case  of  gall-stones,  bilious  motions  may  coexist 
with  jaundice  which  has  resulted  from  obstructed  bile-ducts. 
Secondly,  if  the  motions  be  thin  or  watery,  they  may  appear  to 
contain  bile  from  the  admixture  of  jaundiced  urine.  Thirdly, 
in  rare  cases  the  bile-duct  is  only  partially  occluded  and 
sufficient  bile  passes  to  colour  the  fasces.  And  fourthly,  some 
cases  of  jaundice  have  a  complex  origin,  there  being  both 
occlusion  of  the  duct  and  a  morbid  state  of  blood. 

2.  A  tumour  corresponding  to  the  region  of  the  gall- 
bladder will  favour  the  view  that  the  jaundice  is  due  to  ob- 
struction of  the  bile-duct  (p.  161). 

3.  Jaundice  which  persists,  and  is  3'et  slight,  is  most 
probably  independent  of  obstruction  of  the  bile-duct.  Per- 
sistent jaundice  from   obstruction    speedily  becomes   intense ; 

'  A  guide  to  tlie  qualitative  and  qimntitative  Analysis  of  the  Urine,  by  Dr.  C. 
Neubauer  and  Dr.  J.  Vogel,  Syd.  Hoc.  Trausl.  p.  48. 


LBCT.  XI.  DIAGNOSIS    OF   CAUSES.  43 1 

but  in  reference  to  this  you  must  remember,  what  I  have  so 
often  insisted  upon,  that  even  when  there  is  irremovable 
obstruction  of  the  bile-duct,  the  intensity  of  the  jaundice  will 
vary  from  time  to  time  according-  to  the  amount  of  bile  secreted 
by  the  liver  and  the  activity  of  the  kidneys,  and  that  in  the 
advanced  stag-e  the  jaundice  may  permanently  fade  in  con- 
sequence of  the  destruction  of  the  glandular  tissue  and  the 
small  quantity  of  bile  which  is  secreted. 

4.  Jaundice  appearing  suddenly  in  a  person  whose  previous 
health  has  been  good  is  most  probably  the  result  of  obstruction 
of  the  duct  by  a  gall-stone,  or  it  has  a  nervous  origin.  In 
the  former  case  it  will  be  preceded  or  accompanied  by  biliary 
colic  and  vomiting,  and  the  stools  will  be  cla^- -coloured  :  in 
the  latter  there  will  be  a  history  of  concussion  or  of  some 
severe  mental  emotion,  the  motions  will  contain  bile,  and  the 
jaundice  will  be  often  accompanied  by  delirium  and  other 
cerebrals  ymptoms. 

5.  Jaundice  coming  on  very  slowly,  but  ultimately  becoming 
intense,  with  complete  disappearance  of  bile  from  the  motions, 
is  most  probably  the  result  of  pressure  on  the  bile-duct  from 
without,  or  of  the  growth  of  some  tumour  in  the  interior  of 
the  duct  (pp.  352-3). 

6.  Several  attacks'of  temporary  jaundice  with  distinct  inter- 
missions point  to  gall-stones,  if  the  patient  be  of  adult  or 
advanced  life  (p.  340) ;  in  early  life,  to  catarrh  of  the  duodenum 
or  bile-ducts  (p.  346). 

7.  Pain  is  present  in  some  cases  of  jaundice,  absent  in 
others.  There  may  be  little  or  no  pain  in  cases  where  the 
cause  is  a  duodenal  ulcer,  a  simple  stricture  of  the  duct, 
enlarged  glands  in  the  fissure  of  the  liver,  or  the  poison  of 
some  specific  fever.  It  is  well  also  to  remember  that  in  very 
rare  cases  a  gall-stone  has  been  known  to  obstruct  the  com- 
mon duct  and  cause  permanent  jaundice,  without  ever  having 
excited  attacks  of  biliary  colic.  A  pain  coming  on  in  severe 
paroxysms,  and  then  subsiding,  may  result  from  :  a,  gall-stones 
(see  p.  337) ;  5,  hydatids  (p.  344)  ;  c,  a  duodenal  ulcer  (p.  349) ; 
and,  d,  an  aneurism  of  the  hepatic  artery  (p.  357).  Jaundice 
immediately  preceded  by  severe  paroxsyms  of  pain  is  most 
probably  due  to  gall-stones ;  jaundice  followed  by  severe 
paroxysmal  pain  is  more  probably  the  result  of  cancer.  Pain, 
more  or  less  constant,  with  tenderness  on  pressure  below  the 
right  ribs,  will  indicate  that  the  jaundice  depends  on :  a,  con- 


432  JAUNDICE.  LECT.  XI. 

gestion  of  the  liver  (p.  132);  h,  interstitial  hepatitis  (p.  139)  ; 
c,  catarrli  of  the  bile-ducts  (p.  152)  ;  d,  pyaemia  with  purulent 
deposits  in  the  liver  (p.  165)  ;  e,  cancer  of  the  liver  (p.  210), 
/,  acute  atrophy  of  the  liver  (p.  261).  Lastly,  in  reference  to  the 
concurrence  of  pain  and  jaundice  you  must  remember  that  cancer 
of  the  gall-bladder  is  not  an  uncommon  sequel  of  gall-stones. 

8.  Jaundice  concurring  with  great  enlargement  of  the  liver 
is  most  probably  due  to  cancer  of  the  liver  (p.  208)  ;  but  it 
may  also  arise  from  waxy  liver,  when  the  bile-duct  is  compressed 
by  enlarged  glands  in  the  portal  fissure  (p.  33),  from  multiple 
abscesses  of  the  liver  (p.  167),  or  from  interstitial  hepatitis 
(p.  140). 

9.  The  diagnosis  of  the  cause  of  jaundice  is  often  materially 
assisted  by  the  coexistence  with  it  of  ascites.  When  these 
two  conditions  coexist,  you  will  usually  find  that  there  is  either 
cancer  or  cirrhosis.  When  permanent  jaundice  with  complete 
absence  of  bile  from  the  motions,  and  ascites  without  dropsy 
elsewhere,  are  present  in  the  same  case,  you  will  rarely  be 
wrong  in  inferring  that  the  obstruction  of  the  gall-duct  which 
causes  the  jaundice,  and  the  obstruction  of  the  portal  vein 
from  which  the  ascites  results,  are  due  to  a  common  cause. 
That  cause  cannot  be  a  gall-stone.  This  will  obstruct  the  bile- 
duct,  but  cannot  obstruct  the  flow  of  blood  in  the  portal  vein, 
so  as  to  produce  ascites.'  The  double  obstruction  is  most  likely 
to  be  caused  by  pressure  from  without  upon  the  gall-duct  and 
portal  vein,  where  they  lie  side  by  side  in  the  fissure  of  the 
liver,  by  enlarged  lymphatic  glands,  by  a  tumour  in  the  head  of 
the  pancreas,  or  by  cancerous  nodules  projecting  from  the 
surface  of  the  liver  itself.  It  is  quite  possible,  however,  for 
these  lesions  to  cause  jaundice  without  ascites.  In  the  ad- 
vanced stage  of  cirrhosis  it  is  also  not  uncommon  for  jaundice 
to  coexist  with  ascites ;  but  then  the  liver  is  often  small,  the 
jaundice  is  slight,  little  more  than  sallowness,  and,  what  is 
more  important,  the  colour  of  the  motions  proves  that  bile-pig- 
ment is  still  secreted,  and  finds  its  way  into  the  bowel.  There 
is  not  a  complete  absence  of  bile-pigment  from  the  excrement. 

10.  In  a  large  proportion  of  cases  of  jaundice  the  pulse  is 
unusually  slow  and  the  temperature  is  not  increased.  When 
jaundice  is  accompanied  by  febrile  symptoms,  the  probable 
causes  are :  a,  inflammation  or  ulceration  of  the  bile-ducts 
(p.  153)  ;  h,  some  specific  fever  (p.  395)  :  c,  pycemia  (pp.  165, 
404)  ;  tubercle  (p.  245)  ;  or  inflanKnl  hydatid  (p.  69). 

'  But  SCO  Locturc  XIII „  Case  CLXVII. 


LECT.  XT.  DIAGNOSIS    OF    CAUSES.  433 

11.  Delirium,  stupor,  and  other  cerebral  symptoms  con- 
curring- with  jaundice  suggest :  a,  acute  atrophy  of  the  liver 
(pp.  262,  322)  ;  6,  poisoning  hj  phosphorus  (p.  405) ;  c,  some 
specific  fever  or  other  blood-poison  (p.  395) ;  d,  nervous  shock 
(p.  409);  or  e,  pneumonia  (p.  411).  In  all  these  cases  the  sym- 
ptoms are  those  of  an  acute  illness,  the  stools  contain  bile,  and 
the  urine  often  contains  leucin  and  tyrosin  and  is  deficient  in 
urea.  Similar  symptoms,  however,  may  also  supervene  in  cases 
of  protracted  jaundice  from  obstruction  of  the  bile-duct,  in 
which  the  stools  contain  no  bile  (p.  273). 

12.  In  diagnosing  the  cause  of  jaundice  it  is  always  impor- 
tant to  keep  in  view  the  condition  of  the  patient  prior  to  its 
appearance.  In  the  case  of  jaundice  from  gall-stones  or  nerv- 
ous shock  the  patient  may  have  been  in  excellent  health  previ- 
ously. In  catarrhal  jaundice  the  attack  is  preceded  for  a  week 
or  ten  days  by  gastric  symptoms  with  vomiting  or  diarrhoea  (p. 
152).  Emaciation  with  loss  of  appetite,  flatulence,  and  vomit- 
ing of  food  prior  to  the  jaundice  ought  to  suggest  cancer  of 
the  pancreas,  duodenum,  or  pylorus  (pp.  352,  354),  and  pain 
two  or  three  hours  after  a  meal  with  attacks  of  hsematemesis 
or  melaina  will  point  to  a  duodenal  ulcer  (p.  348).  Jaundice 
occurring  in  the  course  of  specific  fevers  or  pyaemia  will  be 
preceded  by  the  s^^mptoms  characteristic  of  these  disorders. 
Jaundice  in  the  early  stage  of  pregnancy  may  be  due  to  con- 
gestion of  the  liver  from  suppression  of  the  catamenia  (p. 
134) ;  in  the  more  advanced  stages  it  may  arise  from  pressure 
of  the  enlarged  uterus  upon  the  bile-duct  (p.  358),  or  from 
acute  atrophy  (p.  265).  Lastly,  true  jaundice  in  the  new-born 
child  may  result  from  the  inhalation  of  a  vitiated  atmosphere 
(p.  411),  from  plugging  of  the  bile-duct  by  inspissated  bile  or 
gall-stones  (p.  342),  or  from  congenital  closure  or  deficiency 
of  the  duct  (p.  346). 


P  P 


434  FLUID    IN    THE    PEEITONETJM.  lect.  xii. 


LECTURE   XII. 
FLUID  IN  THE  PERITONEUM. 

ITS     SIGNS THE    CONDITIONS    WHICH     SIMULATE     IT,    AND     HOW    TO    DISTINGUISH     THEM  : 

1.    OVARIAN    CYST  :     2.    HYDATID    TUMOUR  ;     3.    RENAL    CYST  ;    4.    DISTENDED    URINARY 

BLADDER  ;     5.     PREGNANT     UTERUS CAUSES     OF    FLUID     IN     PERITONEUM  :     I.    ACUTE 

PERITONITIS  ;  II.  TUBERCULAR  PERITONITIS  ;  III.  CHRONIC  PERITONITIS  ;  IV.  CANCER  ; 
T.  COLLOID  DISEASE;  VI.  SIMPLE  DROPSY  —  1.  FROM  DISEASE  OF  KIDNEYS;  2.  FROM 
DISEASE   OF   HEART    OR    LUNGS  ;    3.    FROM    PORTAL    OBSTRUCTION. 

Gentlemen, — Pursuing  a  similar  course  to  that  adopted  when 
I  was  lecturing  on  enlargements  of  the  liver  and  jaundice,  I 
purpose  to-day  laying  before  you  the  various  causes  of  fluid  in 
the  peritoneum  and  the  means  of  distinguishing  them,  more 
especially  in  reference  to  diseases  of  the  liver,  of  which  ascites 
is  so  common  a  symptom. 

The  signs  of  fluid  in  the  abdominal  cavity  are  as  follows  : — 

1.  There  is  enlargement  or  swelling  of  the  abdomen. 

2.  A  dull  sound  is  elicited  on  percussion  over  the  seat  of 
fluid.  It  is  very  common  for  persons  in  middle  or  advanced 
life  to  consult  a  medical  man  in  the  belief  that  they  have  got 
dropsy,  the  swelling  being  nothing  more  than  an  accumulation 
of  gas  in  the  bowels,  aided  perhaps  by  an  increase  of  the  sub- 
cutaneous fat.  The  nature  of  the  case  will  be  at  once  revealed 
by  percussion,  which  will  give  forth  a  clear  sound  over  a  tym* 
panitic  bowel.  In  rarer  cases,  which  are  sometimes  mistaken 
for  pregnancy,  the  abdomen  is  protuberant  and  more  or  less 
tympanitic,  owing  to  abnormal  contraction  of  certain  of  the 
abdominal  muscles  and  particularly  of  the  diaphragm. 

3.  A  peculiar  thrill  or  sense  of  fluctuation  on  percussion. 
This  is  elicited  by  laying  the  left  hand  flat  on  the  side  of  the 
abdomen  and  then  tapj>ing  abruptly,  but  gently,  on  the  other 
side  with  the  fingers  of  the  right  hand.  This  thrill  is  always 
most  decided  when  the  quantity  of  liquid  accumulated  is  great, 
and  when  the  abdominal  wall  is  thin  and  tense  ;  but  even  a  few 


LECT.  XII.  CONDITIONS    SIMULATING   IT.  435 

ounces  may  be  detected  bj  skilful  hands.  In  this  case,  how- 
ever, you  must  not  expect  to  get  the  thrill  propagated  from  one 
sideC-of  the  abdomen  to  the  other,  but  you  must  apply  the 
fingers  of  the  left  hand  over  the  upper  margin  of  the  part  that 
is  dull  on  percussion,  and  tap  on  the  dull  part  a  few  inches 
below  with  the  fingers  of  the  right  hand. 

4.  Pressure  will  sometimes  give  unmistakable  evidence  of 
fluid  in  the  abdomen.  If  pressure  be  made  with  the  tips  of  the 
fingers  suddenly  and  perpendicularly  to  the  surface,  you  will 
frequently  experience  a  sensation  of  the  displacement  of  liquid 
and  of  3'our  fingers  coming  in  contact  with  some  solid  body, 
such  as  an  enlarged  liver  or  spleen,  or  a  tumour. 

5.  When  the  quantity  of  fluid  is  great,  it  will  interfere  with 
the  proper  action  of  the  diaphragm  and  abdominal  muscles, 
and  cause  more  or  less  dyspncea  and  thoracic  breathing. 

6.  In  cases  also  where  there  is  a  large  accumulation  of 
liquid  the  patient's  head  is  often  thrown  back  in  standing  or 
walking,  to  balance  the  body.  The  same  gait  is  constantly 
observed  in  the  advanced  stage  of  pregnancy. 

7.  Mere  accumulation  of  liquid  in  the  abdomen,  by  com- 
pressing the  renal  and  iliac  veins,  may  give  rise  to  albuminuria 
and  anasarca  of  the  legs,  but  these  are  important  characters  to 
which  we  shall  return  presently. 

CONDITIONS    SIMULATING-    FLUID    IN    THE    PEEITONEUM. 

When  the  characters  now  enumerated  are  present,  you  may 
be  perfectly  sure  that  you  have  to  deal  with  a  collection  of  fluid 
in  the  abdomen,  but  they  are  not  sufficient  to  enable  you  to  say 
whether  the  fluid  be  in  the  peritoneal  cavity  or  in  a  distinct 
cyst,  and  this  is  the  next  point  which  you  must  always  pro- 
ceed to  determine.  Fluid  in  the  peritoneum  is  most  readily 
simulated  by:  1 ,  an  ovarian  cyst ;  2,  a  hydatid  tumour;  3,  a 
large  cyst  attached  to  the  kidney ;  4,  a  distended  urinary 
bladder ;  or,  5,  a  pregnant  uterus :  and  in  practice  it  is  very 
necessary  that  you  should  avoid  confounding  with  it  any  of 
these  conditions. 

1.  An  Ovarian  Cyst. 

From  its  great  frequency  this  is  the  condition  most  apt  to 
be  mistaken  for  ascites.  As  long  as  an  ovarian  tumour  is  small, 
its  outline  can  be  felt  through  the  abdominal  parietes  and  the 
diagnosis  is  easy.     The  difficulty  arises  when  the  cyst  is  very 

F   F   2 


436 


FLUID    IN    THE    PERITONEUM. 


lai'ge  and  appears  to  fill  the  abdomen.'  Even  then,  however,  it 
is  readily  distinguished  from  ascites  by  the  following-  characters, 
most  of  which  also  serve  to  distinguish  ascites  from  other,  as 
well  as  ovarian,  cysts  in  the  abdomen  containing  fluid  : 

1.  In  ascites  the  fluid,  being  free  to  move  about  among  the 
bowels,  always  gravitates,  and  the  intestines  containing  gas 
float  on  the  surface,  whatever  be  the  position  of  the  patient. 
Consequently,  when  the  patient  lies  on  his  back,  there  will  be 
dulness    on  percussion  in  the  flanks  and  a  clear  tympanitic 


Fig.  30  illustrates  the  pcrcusi-ion-sounds  over  the  abdonien  in  a  case  of  ascites  from 
cirrhosis  of  the  liver. 

a.  Dulness  of  contracted  liver.    6.  Fluid  in  peritoneum  causing  bulging  of  ttie  flanks,    c.  Tympanitic 
intestines,    d.  Enlarged  spleen,    e.  Heart. 

circular  space  of  greater  or  less  extent  around  the  umbilicus, 
generally  more  above  the  umbilicus  than  below  it,  inasmuch  as 
patients  lie  mostly  with  the  shoulders  more  elevated  than  the 
pelvis.  When  the  patient  lies  on  his  right  side,  this  clear 
space  will  shift  to  the  left ;  and  when  he  lies  on  the  left  side,  it 
will  shift  to  the  right.  Even  small  amounts  of  fluid  may  be 
detected  by  making  the  patient  rest  upon  his  elbows  and  knees, 
when  the  fluid  will  gravitate  to  the  umbilicus.     In  any  situa- 


'  Tiiese  remarks  apply  only  to  those  cases  where  the  tumour  is  entirely  or  mainly 
composed  of  one  cyst.  Multilocular  ovarian  cysts  are  readily  distinguished  from 
ascites  by  their  uneven  surface,  greater  hardness  and  resistance  on  pressure,  and  by  the 
comparatively  obscure  fluctuation.  » 


CONDITIONS    SIMULATING   IT. 


437 


tior,  the  dulness  on  percussion  will  often  disappear  at  its 
margin  on  deep  pressure.  But  in  ovarian  dropsy  the  cjst  ascends 
in  front  of  the  intestines,  which  are  prevented  from  coming-  in 
front  of  it  by  the  mesentery,  and  which  are  pressed  back  by 
the  tumour  against  the  spine.  Accordingly,  if  there  be  any 
tympanitic  resonance,  it  will  be  in  one  or  both  flanks,  or  in  the 
epigastrium,  and  the  umbilical  region  will  be  dull,  while  the 
relative  position  of  the  clear  and  dull  spaces  will  not  vary  with 
the  posture  of  the  patient.     These  important  differences  between 


Fig.  31  illustrates  the  percussion-sounds  over  the  abdomen  in  a  case  of  tumour  of  tiie 
left  ovary.  The  dulness  of  the  tumour  occupies  the  centre  of  the  abdomen,  Avhicli 
on  either  side  is  tympanitic. 

ascites    and    ovarian   dropsy   are  illustrated   in  the   annexed 
diagrams  (figs.  30  and  31). 

2.  In  ascites  the  swelling  of  the  abdomen  is  uniform  and 
symmetrical  from,  the  first,  and  when  the  patient  lies  on  his 
back,  the  weight  of  the  fluid  causes  a  bulging  on  either  side  and 
gives  an  appearance  of  increased  breadth  to  the  trunk.  But  in 
ovarian  disease  the  swelling  commences  in  one  flank,  and  for  a 
long  time  is  more  on  one  side  of  the  abdomen  than  on  the 
other ;  and  at  this  stage  also,  when  the  hand  is  pressed  back 
through  the  abdomen,  so  as  to  feel  the  lower  part  of  the  spine, 
the  tumour  may  be  felt  to  pass  down  into  the  pelvis.  When 
large,  although  it  may  appear  to  fill  one  side  of  the  abdomen 
as  much  as  the  other,  it  bulges  forwa.rds  rather  than  laterally. 


438  FLUID    IN    THE    PEEITONEUM.  Lect.  xii. 

3.  In  ascites  the  distances  between  the  umbilicus  and  the 
pubes  and  stei-num  maintain  their  normal  ratio,  the  navel  being 
about  an  inch  nearer  to  the  pubes  than  to  the  sternum  ;  but  in 
the  case  of  ovarian  tumour  this  ratio  is  often  reversed.  In  the 
latter  also,  but  never  in  ascites,  the  distance  between  the 
umbilicus  and  the  crest  of  the  ilium  may  differ  on  the  two  sides, 
being  greater  on  the  side  from  which  the  tumour  has  sprung. 
In  ascites,  when  the  patient  is  recumbent,  the  greatest  girth  of 
the  abdomen  is  usually  at  the  umbilicus  or  a  little  above  this ; 
but  in  ovarian  tumour  it  is  more  commonly  an  inch  or  two 
below  this. 

4.  In  both  ascites  and  ovarian  tumour  there  is  often 
obliteration  of  the  umbilicus,  but  in  simple  ovarian  tumour 
there  is  never  an}^  protuberance  of  the  umbilicus,  as  is  common 
in  ascites.  This  is  sometimes  a  sign  of  some  importance  as 
indicating  the  supervention  of  ascites  on  ovarian  tumour. 

5.  There  is  often  a  diflFerence  between  ascites  and  ovarian 
dropsy  in  the  fluid  drawn  off  by  tapping.  In  ascites  it  is  either 
a  clear,  straw-coloured  water,  having  a  specific  gravity  of  about 
1015,  and  containing  a  large  quantity  of  albumen,  or,  if  there 
has  been  any  inflammation  of  the  peritoneum,  the  fluid  may  be 
turbid  and  contain  fla-kes  of  lymph  ;  whereas  the  fluid  from  an 
ovarian  cyst,  although  sometimes  thin  and  almost  colourless 
like  that  of  ascites,  is  often  of  a  glutinous  consistence  or  of  a 
brownish  or  chocolate  colour  from  the  admixture  of  blood. 

By  attention  to  these  rules,  you  will  seldom  have  much 
difliculty  in  distinguishing  between  ascites  and  ovarian  dropsy. 
There  are,  however,  certain  sources  of  fallacy  in  the  diagnosis 
which  it  is  necessary  to  keep  in  view. 

a.  When  the  quantity  of  fluid  in  the  peritoneum  is  very 
great,  the  mesentery  may  not  be  broad  enough  to  allow  the 
intestines  to  float  to  the  surface,  and  consequently  there  may 
nowhere  be  any  tympanitic  sound  elicited  on  jtercussion  of  the 
abdomen. 

b.  The  intestines  in  ascites  may  be  prevented  from  floating 
by  old  adhesions  or  by  a  diseased  omentum  binding  them  dowji 
to  the  spine.  In  cases,  for  instance,  of  sub-acute  or  chronic 
peritonitis,  the  intestines  may  be  matted  together  and  bound 
down  to  the  back  of  the  abdomen  by  old  adhesions,  while  fluid 
collects  between  them  and  the  abdominal  wall  in  front  (see  Case 
CLIL). 

c.  In  very  rare  cases  an  ovarian  tumour  has  a  coil  of  b(»wel 


LBCT.  XII,  CONDITIONS    SIMULATING    IT.  439 

stretched  over  it,   whicli  may  yield  a  tympanitic  percussion - 
sound. 

d.  An  ovarian  cyst  may  contain  air  as  well  as  fluid,  owing 
to  decomposition  of  its  contents  after  tapping,  or  to  its  having- 
effected  a  communication  with  some  portion  of  the  bowel,  as 
in  Case  CXLVIII.  Under  these  circumstances  you  may  have 
an  ovarian  cyst  with  tympanitic  percussion-sound  at  the  um- 
bilicus. 

e.  Occasionally  there  is  a  concurrence  in  the  same  person 
of  ascites  and  ovarian  tumour.  In  this  case,  when  the  patient 
is  supine,  there  is  dulness  on  percussion  at  the  umbilicus  as  well 
as  in  the  flanks ;  but  if  he  lie  on  the  side  from  which  the  ovaria,n 
tumour  springs,  the  percussion  over  the  opposite  side  may  be 
tympanitic.  By  pressing  suddenly  also  with  the  points  of  the 
finger  on  the  abdomen,  in  the  manner  already  described,  you 
may  experience  a  sensation  of  displacing  fluid,  and  at  the  same 
time  of  impinging  upon  an  elastic  tumour. 

2.  Hydatid  Tumour. 

It  is  not  often  that  a  hydatid  tumour  fills  the  abdomen  to 
such  an  extent  as  to  be  readily  mistaken  for  ascites,  but  occa- 
sionally a  mistake  of  this  sort  is  apt  to  arise.  You  will  re- 
member that  in  a  former  lecture  (Case  XXXVIII.,  p.  122)  I 
related  to  you  the  case  of  a  girl  of  15,  in  whom  a  hydatid  tumour 
springing  from  the  liver  caused  such  an  enlargement  of  the 
abdomen  as  seriously  to  embarrass  the  function  of  respiration 
and  threaten  death  from  asphyxia — which  was  only  temporarily 
averted  by  drawing  off  248  oz.  of  fluid  by  paracentesis,  and 
where  the  real  nature  of  the  case  was  only  disclosed  on  post- 
mortem examination.  Such  a  case,  however,  ought  to  be  dis- 
tinguished from  ascites  by  the  following  characters  : 

1.  By  the  swelling  being  in  the  first  instance  unsymmetri- 
cal,  or  confined  to  one  portion  of  the  abdomen,  generally  the 
hepatic  region,  before  it  becomes  general.  Most  commonly  a 
hydatid  cyst  commences  in  the  hepatic  region  and  grows  down- 
wards, but  the  possibility  of  its  originating  in  the  pelvis  and 
growing  upwards  must  be  kept  in  view.^ 

'  See,  for  instance,  a  case  recorded  by  Dr.  Habershon  in  the  Pathological  Trans- 
actions (vol.  xi.  p.  155),  where  the  tumour  reached  as  high  as  the  ximbilicus  and 
exactly  resembled  a  distended  urinary  bladder;  another  reported  by  Mr.  Bryant, 
where  it  reached  as  high  as  the  scrobiculus  cordis  (Path.  Trans,  vol.  xA'ii.  p.  278) ; 
and  a  third  reported  in  my  paper  on  Hydatid  Tumours  in  the  Edin.  Med.  Joiirn.  for 


440  FLUID    IN    THE    PEEITONEUM.  lect.  Xii. 

2.  By  the  tjaiipanitic  portion  of  the  abdomen  not  always 
being  most  elevated  whatever  posture  the  patient  assumes. 
In  the  case  already  referred  to  there  was  tympanitic  percussion 
in  both  flanks,  while  the  anterior  portion  of  the  abdomen  was 
dull  and  fluctuating. 

3.  By  the  fluid  drawn  off  being  clear  and  limpid,  strongly 
impi'egnated  with  common  salt,  but  devoid  of  albumen  or 
urea  (see  p.  61). 

In  those  rare  cases  already  referred  to  (pp.  56,  69)  where 
ascites  coexists  with  hydatid  tumour,  the  difficulty  of  diagnosis 
will  be  considerable. 

3.  A  Renal  Cyst. 

A  cyst  attached  to  the  kidney  occasionally  acquires  such 
dimensions  as  to  cause  great  enlargement  of  the  abdomen. 
Not  long  ago  you  had  an  opportunity  of  seeing  a  case  of 
this  sort  (see  Case  VIII.  p.  27),  where  a  cyst  of  the  right 
kidney  contained  upwards  of  200  oz.  of  fluid.  However  large 
such  a  cyst  may  be,  it  is  always  easily  distinguished  from 
ascites  : 

1.  By  the  signs  of  fluid  being  limited  to  one  side  of  the 
abdomen,  and  by  the  tympanitic  intestines  being  pushed  over 
to  the  other,  in  whatever  posture  the  patient  lies. 

2.  By  there  being  often  a  history  of  some  injury  to  the 
kidney  years  before. 

3.  By  there  being  often  a  history  of  haematuria  or  albu- 
minuria, or  of  some  symptoms  of  urinary  irritation.  It  is  im- 
portant, however,  to  remember  that  enormous  renal  cysts  may 
exist  independently  of  any  urinary  symptoms  (see  p.  27). 

4.  The  fluid  obtained  by  tapping  may  contain  urea,  and  on 
adding  nitric  acid  to  the  alcoliolic  extract  crystals  of  nitrate  of 
urea  would  be  produced.  Mr.  Stanley  has  recorded  two  cases  of 
this  sort  where  the  fluid  of  the  cyst  contained  urea.^  This 
character,  however,  although  of  value  in  pointing  to  the  origin 
of  a  circumscribed  cyst  in  the  abdomen,  would  not  distinguish 
the  case  from  ascites,  for  in  dropsy  from  diseased  kidneys  the 
fluid  that  collects  in  the  peritoneum  and  elsewhere  has  been 

Dec.  1865,  Case  X.     In  most  of  tliesc  cases  llio  tuiiiuur  interferes  sooner  or  later  with 
micturition. 

'  An  Account  of  two  Cases  of  Rupt  lire  of  t  lie  Ureter  or  Pelvis  of  the  Kidney.  Me- 
dico-Cliirurgical  Transactions,  1841,  vol.  xxvii,  ji.  1. 


LKCT.  XII,  CONDITIONS    SIMULATING    IT.  44 1 

often  sliowii  to  contain  urea  in  large  quantity.  Moreover,  we 
have  already  found  that  urea  is  not  always  present  in  the  fluid 
of  renal  cysts  (see  p.  27). 

4.   A  distended  Urinary  Bladder. 

You  may  think  it  very  improbable  that  a  distended  urinary 
bladder  could  ever  be  taken  for  ascites,  or  indeed  for  anything 
else  than  a  distended  bladder,  but  such  a  mistake  has  more 
than  once  been  committed,  and  there  can  be  no  doubt  that  the 
bladder  in  rare  cases  becomes  so  enormously  distended  as  to 
fill  a  great  part  of  the  abdomen,  and  simulate  ascites  or  cystic 
tumours.  There  is  the  authority  of  Sir  Everard  Home  for  the 
fact  that  John  Hunter  once  actually  tapped  a  distended  bladder 
in  the  belief  that  the  disorder  was  ascites ;  and  from  my  own 
experience  I  am  inclined  to  agree  with  Sir  Thomas  Watson  in 
thinking  that  mistakes  of  this  sort  are  not  uncommon  in  private 
practice.^  They  are  all  the  more  likely  to  occur  from  the  fact  that 
the  patient  often  passes  a  fair  amount  of  normal  urine.  I  show 
you  here  a  bottle  of  urine  obtained  by  paracentesis  from  a 
patient,  who  was  belie\^ed  by  one  of  the  most  experienced  surgeons 
of  the  present  day  to  be  sujfferiag  from  a  large  hydatid  tumour 
of  the  abdomen.  You  may  judge  of  the  size  of  the  bladder  in 
this  case,  when  I  tell  you  that  480  oz.  of  fluid  were  drawn  off 
by  a  small  trocar  introduced  midway  between  the  umbilicus  and 
the  sternum.  The  case  is  one  of  such  importance  in  diagnosis 
that  I  shall  not  be  wasting  your  time  in  relating  it  to  you  in 
detail  (see  Case  CXLIX.).  Case  CL.  is  another  remarkable 
illustration  of  the  same  mistake.  I  may  refer  also  to  a  case 
which  occurred  in  my  practice  a  few  years  ago,  where  a  saccu- 
lus  of  the  bladder  in  a  man  aged  68,  became  so  enormously 
dilated  as  to  form  a  large  tumour  in  the  right  iliac  region, 
which  compressed  the  femoral  vein  and  caused  thrombosis  of 
this  vessel  with  painful  swelling  of  the  leg.^  Cases  of  distended 
bladder  will  be  distinguished  from  ascites  : 

1.  By  there  being  dulness  at  the  umbilicus  and  displace- 
ment of  the  bowels  upwards  and  laterally. 

2.  By  there  being  in  the  earlier  stages  a  central  circum- 

'  Lect.  on  Practice  of  Physic,  5th  edit.  voL  ii.  p.  445. 

^  In  this  case  also  the  patient  passed  normal  urine  freely,  and  seemed  to  have  no 
urinary  symptoms.  The  cyst  was  tapped  midway  between  the  pubes  and  the  spine  of 
the  ilium  and  12  oz.  of  urine  drawn  oiF;  the  operation  was  followed  by  no  bad  con- 
sequence.  The  case  is  fully  reported  in  the  Pathological  Transactions  (vol.  xiv.  p.  133). 


442  FLUID    IN    THE    PEEITOlSrEUM.  iect.  xii. 

scribed   tumour   containing  fluid,  and  growing  upwards  from 
the  pubes. 

3.  By  there  having  been  in  most  cases  at  some  former 
period  symptoms  of  retention  or  of  some  urinary  disturbance, 
even  though  such  symptoms  may  be  absent  subsequently  when 
the  i^atient  first  comes  under  notice. 

4.  Cases  of  this  sort  are  most  common  in  old  men  with 
large  prostates,  where  an  ovarian  cyst,  which  most  closely 
simulates  the  characters  of  a  distended  bladder,  may  be  ex- 
cluded from  the  diagnosis,  and  whenever  from  the  circumstances 
any  doubts  exist  as  to  the  enlargement  being  due  to  the  bladder, 
they  may  be  solved  by  introducing  a  long  prostatic  catheter 
and  j)ushing  it  well  up.  With  an  ordinary  catheter  only  a  few 
ounces  of  urine  may  be  obtained,  and  no  impression  may  be 
made  on  the  tumour,  for,  as  was  long  ago  shown  by  Des- 
champs,^  the  bladder  in  these  cases  bends  over  upon  itself  so 
that  the  greater  part  of  the  viscus  is  shut  off  from  the  neck, 
which  is  also  distended  so  as  to  hold  a  few  ounces  of  the 
urine. 

5.  A  Pregnant  Uterus. 

Although  from  the  time  of  Queen  Marj-  there  have  been 
many  celebrated  instances  of  abdominal  dropsy  being  mistaken 
for  pregnancy,  and  vice  versa,  it  would  be  an  unjustifiable  error 
for  a  medical  man  at  the  present  day  to  mistake  a  solid  enlarge- 
ment of  the  uterus,  accompanied  by  all  the  constitutional  sym- 
ptoms and  local  signs  of  the  pregnant  state,  for  dropsy  of  the 
peritoneum. 

CAUSES    OP    FLUID    IN    THE    PEEITONEUM. 

But  supposing  you  have  decided  that  there  is  really  fluid 
in  the  peritoneal  cavity,  the  next  point  to  determine  is  its 
source  or  cause.  It  may  be  due  to  :  I.  Acute  Peritonitis ;  II. 
Tubercular  Peritonitis  ;  III.  Chronic  Peritonitis  ;  IV.  Cancer  of 
the  Peritoneum ;  V.  Colloid  disease  of  the  Peritoneum ;  or, 
VI.   Simple  Dropsy. 

I.     Acute  peritonitis  is  distinguished  by  : 

1.  Its  rapid  course. 

2.  The    symptoms    of  abdominal    inflammation — pyrexia, 

'  Traits  dc  I'OjxTiition  do  lii  Tiiillo,  toni.  i.  p.  221.  This  is  a  source  of  fallacy  in 
diagnosis  on  which,  thirty  years  ago,  Mr.  .Syaie  was  iu  the  habit  of  strongly  insisting 
in  liis  clinical  lectures. 


LKCT.  XII.  ITS   CAUSES.  443 

witli  small,  rapid  pulse,  shrunken  features,  clammy  sweats,  and 
great  tendency  to  collapse ;  vomiting ;  acute  pain  and  tender- 
ness of  the  abdomen ;  thoracic  breathing ;  and  legs  drawn  up. 

3.  The  quantity  of  fluid  thrown  out  into  the  peritoneum  is 
usually  small,  and  is  often  insufficient  to  produce  a  distinct 
sense  of  thrill  or  flluctuation. 

II.  In  Tubercular  peritonitis  the  tendency  is  to  the  formation 
of  firm  adhesions  of  the  abdominal  viscera  to  one  another  and 
between  them  and  the  abdominal  wall,  without  any  accumula- 
tion of  fluid.  The  abdomen  in  these  cases  is  usually  retracted. 
Occasionally  circumscribed  collections  of  fluid  form  between 
adjacent  coils  of  bowel  (from  tubercular  ulcers  of  the  mucous 
coat  ending  in  perforation,  or  from  mere  softening  of  tubercular 
matter),  and  acquire  such  a  size  as  to  cause  a  bulging  of  the 
abdominal  wall.  In  other  cases  fluid  in  considerable  quantity 
collects  in  the  peritoneal  cavity  as  the  result  of  slight  tubercular 
peritonitis,  probably  associated  with  deposit  of  tubercle  in  the 
portal  lymphatics  which  press  upon  the  portal  vein  (see  Case 
CLVI.).  1  have  met  with  at  least  two  cases  of  this  sort  in  which 
there  has  been  a  simultaneous  collection  of  fluid  in  one  of  the 
pleural  cavities,  and  similar  cases  have  been  observed  by 
Leudet.'  What  is  noticeable  also  about  these  cases  is  that  the 
fluid  is  often  absorbed,  especially  in  the  case  of  children,  and  the 
patient  recovers.  Not  unfrequently  in  tubercular  peritonitis, 
the  fluid  is  purulent,  and  sometimes  it  points  at  the  umbilicus, 
and  more  than  once  I  have  known  the  patient  recover  after  its 
evacuation.  One  remarkable  instance  is  on  record  in  which 
tubercular  peritonitis  was  mistaken  for  ovarian  disease ;  after 
18  pints  of  fluid  had  been  removed  by  tapping,  Mr.  Spencer 
Wells  laid  open  the  peritoneum,  which  was  found  to  be  studded 
with  myriads  of  tubercles,  while  the  intestines  were  matted 
together  and  bound  down  towards  the  back  and  upper  part  of 
the  abdomen.  The  cavity  was  emptied  and  the  wound  closed. 
After  a  sharp  attack  of  peritonitis  the  patient  recovered;  at 
the  end  of  four  years  she  married,  and  six  years  later  she  was 
stout  and  well.^ 

The  symptoms  of  tubercular  peritonitis  are  often  obscure, 
but  it  may  generally  be  recognised  by  the  following  characters  : 

1.  The  presence  of  hectic  fever  with  emaciation  and  night- 
sweats. 

'  Clin.  Med.,  Paris,  1874,  p.  506. 

-  Dr.  Hilton  Fagge.     Guy's  Hcsp.  Rep.  1875,  vol.  sx. 


444  FLUID    IN    THE    PERITONEUM.  iECT.  xit. 

2.  The  concnrrence  of  signs  of  tubercle  in  other  parts  of 
the  body. 

3.  Diarrhoea  is  not  uncommon. 

4.  In  some  cases  there  are  pa'n  and  tenderness,  but  not 
acute,  in  the  abdomen. 

5.  Occasionally  hard  masses  of  indurated  omentum  can  be 
felt. 

III.  Chronic  Peritonitis,  independent  of  either  tubercle  or 
cancer,  is  not  very  uncommon.  Its  pathology  has  not  yet  been 
satisfactorily  Avorked  out.  In  some  cases  the  inflammation 
seems  to  start  from  one  of  the  subjacent  viscera,  and  in  others  the 
patient  is  of  broken-down  constitution — very  often  the  subject 
of  Bright's  disease.  The  intestines  in  these  cases  become  matted 
together  and  tied  down  to  the  spine,  and  fluid  accumulates  in 
considerable  quantity  between  them  and  the  abdominal  w\all 
in  front  (see  Case  CLII.).  These  cases  are  distinguished  as 
follows  : 

1.  There  is  symmetrical  and  rarely  very  great  enlargement 
of  the  abdomen. 

2.  There  is  distinct  fluctuation,  but  nowhere  tj-mpanitic 
percussion-sound,  except  perhaps  at  the  epigastrium. 

3.  There  is  in  most  cases  slight  fever  with  pain  and  tender- 
ness of  abdomen  and  thoracic  breathing — the  symptoms  in 
fact  of  acute  peritonitis  in  a  very  modified  form.  Occasionally 
the  symptoms  at  the  commencement  ai-e  those  of  acute  peri- 
tonitis. 

4.  The  diagnosis  may  be  assisted  by  there  being  an  absence 
of  other  causes  of  fluid  in  the  jDeritoneum,  such  as  disease  of 
the  heart,  liver,  or  kidneys. 

There  are  certain  cases  which  seem  to  constitute  a  connect- 
ing link  between  inflammation  and  dropsy  of  the  peritoneum, 
where  the  attack  commences  with  symptoms  of  subacute 
inflannnation,  but  subsequently  takes  on  more  the  characters  of 
dropsy.  These  attacks  are  most  common  in  children  and  in 
women,  and  in  the  latter  are  often  associated  with  some  in- 
flammatory condition  of  the  pelvic  organs,  or  the  leakage  of 
an  ovarian  cyst.  The  dropsical  eff'usion  in  these  cases  often 
rapidly  disajjpears  under  treatment.  I  have  met  with  persons 
in  advanced  life  who  have  had  attacks  of  this  sort  when  children, 
for  which  a  large  quantity  of  fluid  has  been  drawn  off  by 
paracentesis,  and  who  have  made  a  complete  and  permanent 
recovery.     It  is  jiossible  that  the  inflammatory  process  in  the 


I.KCT.  XII.  ITS   CAUSES.  445 

first  instance  causes  obstruction  of  certain  of  tlie  mesenteric 
veins,  as  the  result  of  wliich  dropsical  effusion  takes  place, 
which  disappears  on  the  removal  of  the  obstruction,  or  on  the 
enlargement  of  collateral  veins.  To  this  class  probably  belong 
the  cases  referred  to  by  Sir  Thomas  Watson  nnder  the  designa- 
tion of  active  ascites,  where  fluid  is  rapidly  thrown  out  into  the 
peritoneum  after  exposure  to  cold  and  wet,  without  fever  or 
any  sign  of  inflammation,  and  independently  of  any  disease  of 
the  liver,  heart,  or  kidneys,  and  where  after  a  short  time  it  is 
reabsorbed.^  Professor  Leudet  of  Rouen  also  has  Avithin  the 
last  few  years  published  a  number  of  interesting  observations, 
illustrating  the  curability  of  ascites  resulting  from  subacute 
inflammation  of  the  peritoneum. ^  Case  CLVIII.  appears  to  be 
an  example  of  this  form  of  dropsy. 

IV.  Cancer  of  the  PeritonetiTn. — It  is  not  often  that  the  peri- 
toneum is  the  seat  of  cancer,  but  cases  are  every  now  and  then 
met  with,  where  cancer  commences  in,  and  at  death  is  still 
limited  to,  the  peritoneum.  The  peculiarity  of  these  cases  is 
that  there  always  is  more  or  less  pain,  with  the  effusion  usually 
of  a  large  quantity  of  fluid  into  the  peritoneal  cavity,  often 
necessitating  paracentesis  to  avert  asphyxia,  and  in  this  respect 
presenting  a  striking  contrast  to  tubercular  peritonitis.  Tou 
ought  always  to  suspect  cancer  of  the  peritoneum  when  you 
meet  with  pain  and  effusion  in  the  abdomen  in  aged  persons. 
Six  cases  answering  to  this  description  have  come  under  my 
notice,  and  in  two  you  will  observe  that  the  patients  were  under 
forty  years  of  age.  Three  of  the  cases,  Jane  0.,  aged  51, 
Catherine  H.,  aged  38,  and  Mary  Anne  P.,  aged  48,  I  shall 
presently  describe  to  you  in  detail  (Cases  CLIII.  to  CLY.).  The 
fourth  was  the  case  of  a  rickety  female,  aged  78,  who  died  in 
Middlesex  Hospital  on  Oct.  10,  1860,  whose  abdomen  was  enor- 
mously distended  with  many  quarts  of  flaky  fluid,  and  the  intes- 
tines studded  on  their  peritoneal  surface  with  numerous  small 
nodules  of  cancer  of  about  the  size  of  split-peas.  Three  months 
before  death  she  had  been  attacked  with  vomiting  and  abdominal 
pain,  accompanied  by  emaciation,  and  followed  after  six  weeks 
by  ascites,  rapidly  increasing  till  death.  The  fifth  was  the  case 
of  a  man  aged  89,  who  died  in  Middlesex  Hospital  on  Feb.  19, 
1861,  and  in  whose  body  I  found  appearances  precisely  simi- 
lar to  those  in  the  fifth  case.     His  illness  had  commenced  2-|- 

'  Lect.  on  Med.  oth  ed.  ii.  430.  '^  Clin.  Med.  Paris,  ISZ^,  p.  516. 


446  FLUID    IN    THE    PERITONEUM.  lect.  xii. 

montlis  prior  to  death  with  pain  and  tenderness  of  the  abdomen, 
followed  by  rapidly  increasing  ascites.  The  sixth  was  that  of 
a  bargeman,  aged  54,  who  was  under  my  care  in  Middlesex 
Hospital  for  several  weeks  in  the  autumn  of  1863,  whose  illness 
commenced  three  months  prior  to  death  with  an  injury  to  the 
abdomen,  and  in  whose  peritoneum  there  was  also  a  large 
accumulation  of  slightly  turbid  and  flaky  fluid,  with  nodules  of 
medullary  cancer  scattered  over  the  peritoneal  surface  of  the 
different  viscera. 

The  characters  by  which  you  will  recognise  these  cases  are 
the  following  : 

1.  There  are  the  phenomena  of  the  cancerous  cachexia, 
and  perhaps  a  family  history  of  cancer. 

2.  There  is  an  accumulation  of  a  large  quantity  of  fluid  in 
the  peritoneum,  independently  of  disease  of  the  liver,  heart,  or 
kidneys. 

3.  There  is  more  or  less  fever,  with  great  emaciation, 
vomiting,  constipation,  and  severe  pain  and  tenderness  of  the 
abdomen,  approaching  those  of  acute  peritonitis.  From  acute 
peritonitis,  however,  the  affection  differs  in  the  extensive  effu- 
sion of  fluid :  in  ordinary  acute  peritonitis  also  the  tendency  to 
collapse  is  greater  and  the  course  more  rapid. 

4.  It  is  not  often  that  the  nodules  of  cancer  are  large 
enouo-h  to  be  felt  through  the  abdominal  parietes,  but  the 
diagnosis  will  sometimes  be  assisted  by  discovering  a  mass  of 
thickened  omentum  in  the  umbilical  region. 

V.  Colloid  disease  occasional!}^  causes  great  enlargement  of 
the  abdomen  without  any  fluid  in  the  peritoneum.  You  will 
find  two  cases  of  this  sort  recorded  in  the  Pathological  Trans- 
actions by  Dr.  Vanderbyl  and  Dr.  O'Connor.*  I  show  you  here 
specimens  of  the  colloid  disease  from  the  former  case,  which 
proved  fatal  in  this  (Middlesex)  hospital.  Quite  recently,  you 
have  had  a  similar  case  under  your  own  observation.^  These 
cases  may  often  be  recognised  by  the  abdomen  becoming  dis- 
tended by  a  firm  nodulated  mass,  glueing  all  the  organs  together, 
dull  on  percussion  everywhere  in  front,  but  leaving  a  tympanitic 
space  in  either  flank.  But  in  some  cases  colloid  disease,  like 
ordinary  cancer,  leads  to  a  large  accumulation  of  fluid  in  the 
peritoneum  either  from  exciting  peritonitis  or  from  the  rupture 

'   Vol.  ix.  p.  207,  and  vol.  xiii.  p.  90. 

■■^  Emma  B.irrett,  aged  32,  adm.  into  St.  Thomas's  IIosp.  July  10,  and  died  Supt.  5, 
1875. 


LECT.  XII.  ITS    CAUSES.  447 

of  some  of  the  colloid  cysts  and  discharge  of  their  contents, 
and  paracentesis  has  been  necessary  to  relieve  the  breathing. 
(Case  CLXIV).  The  symptoms  in  these  cases  are  very  similar 
to  those  of  primary  cancer  of  the  peritoneum  (Case  CLXIII.). 
There  is  pain  with  tenderness  in  the  abdomen,  often  preceding 
the  signs  of  fluid  for  several  weeks  and  always  accompanying 
them  ;  in  most  cases  there  is  a  certain  degree  of  pyrexia  and 
vomiting ;  but  the  swelling  is  much  greater  than  in  ordinary 
acute  peritonitis.  From  the  first  there  is  rapid  emaciation, 
and  the  case  usually  terminates  fatally  within  six  months  of 
the  commencement  of  the  symptoms.  As  in  cancer  also,  the 
disease  is  chiefly  met  with  in  middle  and  advanced  life  ;  of  nine 
cases  reported  in  the  Pathological  Transactions,  the  ages  varied 
from  37  to  75.  But  from  cancer  of  the  peritoneum  colloid 
disease  differs  in  these  respects  : 

1.  Even  when  the  abdomen  is  very  large,  fluctuation  is 
often  very  indistinct. 

2.  The  fluid  obtained  by  tapping  is  gelatinous,  and  some- 
times so  viscid  that  it  will  not  flow  through  the  cannula.^  At 
other  times  it  is  thin,  but  turbid,  and  contains  blood  and  cells 
of  the  colloid  matter. 

3.  Hard  irregular  masses  or  distinct  tumours  can  sometimes 
be  felt  through  the  abdominal  wall. 

4.  Occasionally  the  patient  voids  per  anum  a  gelatinous  or 
slimy  fluid,  like  white  of  eggs.^ 

VI.  Simple  Dropsy  of  the  Peritoneum. — The  causes  of  fluid 
in  the  peritoneal  cavity  already  referred  to  being  excluded,  its 
presence  must  be  due  to  simple  dropsical  effusion.  This  has 
the  following  characters  : 

1.  There  are  the  signs  of  fluid  in  the  peritoneal  cavity 
already  enumerated  (see  p.  434). 

2.  There  is  an  absence  of  persistent  pain  and  tenderness  of 
the  abdomen,  and  usually  of  pyrexia. 

Simple  dropsy  of  the  peritoneum  may  have  a  threefold 
origin.     It  may  be  due  to  : 

1 .  Diseases  of  the  kidneys. 

2.  Intra-thoracic  diseases. 

3.  Diseases  of  the  liver  or  portal  vein. 

'  This  happened  in  a  case  reported  by  Dr.  Dickinson  in  the  Pathological  Trans- 
actions, vol.  sii.  p.  92. 

^  Two  cases  are  recoi'ded  in  the  Pathological  Transactions  where  this  occurred 

one  by  Dr.  Quain  (vol.  iii.  p.  319),  and  the  other  by  Dr.  O'Connor  (vol.  xiii.  p.  90). 


448  FLUID    IN    THE    PERITONEUM.  lect.  xii. 

Some  writers  have  described  a  form  of  ascites  whicli  tliey 
have  designated  idioiiathic,  to  imply  that  it  is  independent  of 
any  organic  lesion  either  in  the  abdomen  or  elsewhere.  Inas- 
much as  these  cases  usually  recover,  it  may  be  difficult  to 
determine  their  real  pathology,  but  most  of  them  are  probably 
either  tubercular  (see  p.  443)  or  inflammatory  (see  p.  444)  in 
their  origin. 


I.    DROPSY    OF    THE    PERITONEUM    FROM    DISEASES    OF    THE 
KIDNEYS. 

The  diseases  of  the  kidneys  which  are  most  likely  to  induce 
dropsy  are :  a,  acute  nephritis,  occurring  as  a  sequel  of  scarla- 
tina or  from  exposure  to  cold  and  wet,  when  the  kidneys  are 
hypertrophied  and  hypersemic ;  h,  the  so-called  large  white 
kidney,  when  the  cortex  is  pale  and  hypertrophied  and  the 
uriniferous  tubes  crammed  with  granular  epithelium,  and 
which  is  often  merely  an  advanced  stage  of  acute  nephritis, 
but  may  also  be  developed  independently  as  the  result  of  a 
chronic  inflammatory  process ;  c,  the  fatty  kidney,  where  the 
organ  is  also  large  and  pale,  but  the  secreting  cells  are  loaded 
with  oil.  Both  clinical  experience  and  post-mortem  examina- 
tions make  it  probable  that  the  fatty  kidney  is  usually  preceded 
by  the  large  white  form  of  the  disease.  Either  of  these  three 
diseases  of  the  kidneys  may  give  rise  to  ascites,  which  has  the 
following  distinguishing  characters  : 

1.  There  is  anasarca  of  the  subcutaneous  areolar  tissue, 
which  is  general  from  the  first,  and  is  often  noticed  first  in  the 
face. 

2.  There  is  almost  always  evidence  of  fluid  in  the  other 
serous  cavities — the  pleura}  and  pericardium,  as  well  as  in  the 
peritoneum. 

3.  The  urine  is  scanty,  turbid,  or  smoky,  and  contains  a 
large  quantity  of  albumen  and  possibly  blood.  Under  the 
microscope  you  will  usually  find  renal  epithelium  and  casts  of 
the  uriniferous  tubes  varying  in  their  character  according  to  the 
particular  disease  in  the  kidney — ej^ithelial,  blood,  and  hyaline 
casts  in  acute  nephritis  ;  granular  ei^ithelial  casts  in  the  large 
white  kidney  ;  and  oil-casts  in  the  fatty  kidney. 

4.  There  is  a  pallor  and  pastiness  of  the  countenance  which 
is  almost  pathognomonic. 

5.  There  is  a  tendency  to  urtemia  and  the  typhoid  state. 


LECT.  xii.  DISEASE    OF    HEART    OR   LUNGS.  449 

indicated  by  a  dry  brown  tongue,  fetid  breath,  loss  of  memorj'- 
and  restlessness,  delirium,  coma  and  convulsions. 

All  of  these  clinical  characters  you  had  an  opportunity  of 

studying-  in  the  case  of  James  S ,  who  was  lately  under  my 

care  in  Middlesex  Hospital  (Case  CLX.). 

In  forming  a  diagnosis  it  is  necessary  to  remember  that 
most  renal  diseases  predispose  to  inflammation  of  the  serous 
membranes  and  that  thus  the  symptoms  of  peritonitis  may 
concur  with  those  of  renal  dropsy,  and  also  that  the  urine  may 
contain  albumen  although  the  ascites  is  independent  of  disease 
of  the  kidneys  (see  pp.  282,  288). 

Two  common  forms  of  chronic  kidney-disease  are  rarely 
attended  by  dropsy  and  still  more  rarely  by  ascites.  In  the 
contracted,  granular,  or  gouty  kidney  there  is  usually  little  or 
no  dropsy  at  any  stage  of  the  malady ;  while  in  the  waxy,  or 
amyloid  kidney  anasarca  rarely  shows  itself  until  shortly 
before  the  fatal  termination,  and  even  then  is  seldom  excessive 
(see  p.  33).  Both  of  these  diseases  of  the  kidneys  are  marked 
by  the  secretion  of  an  increased  amount  of  urine  and  by  a 
comparative  absence  from  it  of  uriniferous  casts ;  but  in  the 
contracted  kidney  the  specific  gravity  is  low  out  of  all  propor- 
tion to  the  extent  of  dilution,  the  albumen  is  scanty  or  even 
altogether  absent,  there  is  often  a  history  of  gout,  and  there  is 
a  marked  tendency  to  uraemia;  while  in  the  case  of  the  waxv 
kidney  the  lowness  of  the  specific  gravity  of  the  urine  is  not 
more  than  may  be  accounted  for  by  its  dilution,  the  amount  of 
albumen  in  it  is  large,  and  there  is  little  tendency  to  ursemic 
symptoms,  but  in  most  cases  there  are  the  signs  of  waxy 
enlargement  of  the  liver  and  spleen,  exhausting  diarrhoea,  and 
a  history  of  protracted  purulent  discharge  (see  p.  34). 

II.    DROPSY    OF    THE    PERITONEUM    FROM    DISEASES    IN    THE 

CHEST. 

Ascites  is  often  a  consequence  of  obstruction  to  the  general 
circulation  from  various  diseases  of  the  chest,  and  especially 
from  morbid  conditions  of  the  valves  of  the  heart.  Diseases  of 
the  mitral  valve  and  tricuspid  incompetence,  whether  secondary'- 
to  mitral  disease  or  to  chronic  bronchitis  and  emjahysema,  are 
more  likely  to  cause  dropsy  and  ascites  than  lesions  of  the 
aortic  valves.  A  tumour  compressing  the  inferior  vena  cava 
above  its  junction  with  the  hepatic  vein  may  lead  to  a  like  result. 

G  G 


ACQ  FLUID    IN    THE    PEBITONEUM.  lect.  xii. 

Fluid  in  the  peritoneum  due  to  diseases  obstructing  the 
circulation  of  blood  through  the  heart  or  lungs  has  the  follow- 
ing characters  : 

1.  Before  tliere  is  any  ascites  there  is  anasarca,  commencing 
in  the  feet  and  gradually  proceeding  upwards  ;  and  even  when 
the  belly  becomes  swollen,  the  swelling  of  the  legs  is  large  out 
of  all  proportion  to  the  ascites. 

2.  There  is  a  history  of  dyspnoea  before  any  swelling  shows 
itself  in  the  abdomen.  In  extensive  ascites,  whatever  be  its 
cause,  there  is  usually  more  or  less  dyspnoea  from  the  pressure 
of  the  fluid  interfering  with  the  action  of  the  diaphragm  and 
abdominal  muscles.  The  peculiarity  of  the  dropsy  from  intra- 
thoracic disease  is  that  the  dyspncea  precedes  the  ascites  and 
is  distressing  out  of  all  proportion  to  the  extent  of  the  dropsy. 

3.  Intra-thoracic  diseases  which  cause  dropsy  give  rise  at 
the  same  time  to  more  or  less  lividity  of  the  lips,  face,  and 
extremities. 

4.  There  are  the  physical  signs  and  symptoms  of  valvular 
disease  of  the  heart  or  of  old  disease  of  the  lungs.  Even 
■when  the  primary  seat  of  obstruction  is  in  the  heart,  there  will 
be  evidence  of  congestion  or  oedema  of  the  lungs,  or  of  bron- 
chitis, pulmonary  apoplexy,  etc. 

5.  In  the  case  of  a  tumour  compressing  the  inferior  vena 
cava  there  will  be  :  a,  the  physical  signs  of  the  tumour ;  h,  indi- 
cations of  its  pressure  upon  other  parts,  such  as  the  oesophagus 
or  lung  ;  c,  a  more  raj)id  develoj)ment  and  increase  of  anasarca 
than  in  ordinary  cases  of  cardiac  obstruction;  and  d,  great 
enlargement  and  tortuosity  of  the  superficial  veins  of  the  chest 
and  abdomen. 

III.    DROPSY  OF   THE    PERITONEUM    FROM    DISEASES    OF    THE  LIVER 
OR    OF    THE    PORTAL    VEIN. 

The  ascites  which  results  from  obstruction  to  the  circulation 
through  the  trunk  of  the  portal  vein,  or  through  its  ranjifications 
in  the  interior  of  the  liver,  is  that  with  which  at  present  we 
are  more  immediately  concerned,  and  we  shall  therefore  con- 
sider not  merely  the  characters  of  the  ascites  from  portal  ob- 
struction in  general,  but  also  those  which  pertain  to  the  several 
causes  of  this  obstruction.  And  in  the  first  place,  with  regard 
to  the  distinguishing  characters  of  the  ascites  from  any  cause 
of  portal  obstruction.     They  are  as  follows  : 

1.  The   dropsy   in  uncomplicated  portal  obstruction  com- 


LECT.  xii,  DISEASES    OP    LIVER   OR    PORTAL    VEIN.  45 1 

mences  in  the  abdomen.  The  legs  are  only  affected  secondarily 
and  in  consequence  of  the  pressure  of  the  ascitic  fluid  on  the 
inferior  vena  cava.  There  are,  however,  exceptions  to  this  rule. 
Patients  will  tell  you  occasionally  that  they  have  noticed  slight 
swelling  in  the  legs  as  soon  as  the  abdomen  began  to  enlarge  ; 
but  in  these  cases  there  is  this  to  be  noted,  that  the  swelling  of 
the  legs  is  slight  out  of  a,ll  proportion  to  that  of  the  abdomen, 
and  that  when  the  patient  takes  to  bed  it  diminishes  or  entirely 
disappears,  while  the  ascites  remains  stationary  or  increases. 
Outgrowths  from  the  liver,  however,  such  as  occur  in  cancer  and 
cirrhosis,  which  compress  both  the  portal  vein  and  the  inferior 
vena  cava  in  the  notch  at  the  posterior  part  of  the  liver,  may 
cause  permanent  dropsy  both  of  the  legs  and  abdomen.  And 
lastly,  there  are  those  cases  of  chronic  induration  of  the  liver 
with  portal  obstruction  which  are  secondary  to  diseases  in  the 
chest  obstructing  the  general  circulation,  to  which  I  have  for- 
merly adverted  (p.  275) ;  in  such  cases  the  ascites  will  be 
preceded  by  dropsy  of  the  legs,  and  the  addition  of  portal  to 
general  obstruction  is  not  likely  to  be  suspected  unless  there  be 
a  great  preponderance  of  the  dropsy  in  the  peritoneum. 

2.  There  is  no  sign  of  dropsy  in  the  face,  arms,  or  upper 
part  of  the  trunk. 

3.  Dyspnoea  often  accompanies  the  swelling  when  this  is 
great,  but  does  not  precede  it,  except  in  the  one  condition 
already  referred  to  (p.  283). 

4.  Albuminuria  is  absent  if  there  be  no  concurrent  kidney- 
disease.  In  reference,  however,  to  this  point,  there  is  a  source 
of  fallacy.  The  ascites  itself,  when  extensive,  may  in  conse- 
quence of  the  pressure  of  the  fluid  on  the  renal  veins  lead  to  the 
appearance  of  albumen  in  the  urine,  the  albuminuria  ceasing 
on  the  withdrawal  of  the  pressure  by  the  operation  of  paracen- 
tesis. At  the  same  time  you  must  remember  that  albuminuria 
will  not  admit  of  this  explanation,  unless  the  ascites  be  so  great 
as  to  cause  considerable  tension  of  the  abdominal  parietes. 
The  concurrence  of  pufliness  of  the  face,  or  of  pitting  of  the  arms 
or  upper  part  of  the  trunk,  or  the  presence  of  granular  or  oil- 
casts  in  the  urine  would  also  leave  little  doubt  as  to  the  existence 
of  independent  renal  disease. 

5.  In  hepatic  dropsy  the  urine  is  usually  scanty,  high- 
coloured,  and  loaded  with  pigmentary  matter  and  lithates.  The 
absence  of  these  sie^ns  would  be  a  stronof  aroj'ument  asrainst 
either  cancer  or  cirrhosis  of  the  liver. 

G  G  2 


452  FLUID    IN    THE    PERITONEUM.  lect.  xri. 

6.  The  ascites  is  accompanied  by  other  indications  of  portal 
obstruction,  sueli  as  enlargement  of  the  spleen,  enlargement  and 
tortuosity  of  the  superficial  veins  of  the  abdomen,  haimorrhoids, 
gas tro- enteritis  and  hajmorrhages  from  the  stomach  and 
bowels,  which  I  have  already  described  to  you  in  a  former 
lecture  (see  p.  279).  The  enlargement  of  the  superficial  veins 
of  the  abdomen  is  due  to  the  collateral  circulation  established 
through  the  hsemorrhoidal  plexus  between  the  branches  of  the 
portal  vein  and  those  of  the  vena  cava  inferior,  but  is  far  from 
being  a  certain  indication  of  the  existence  of  portal  obstruction. 
The  same  appearance  is  constantly  observed  in  the  ascites  from 
disease  of  the  heart,  and  sometimes  as  the  result  of  pressure  of 
a  tumour  or  even  of  a  large  quantity  of  ascitic  fluid  on  the  in- 
ferior vena  cava  ;  but  in  these  cases  there  will  be  usually  also  a 
varicose  state  of  the  veins  of  the  legs,  although  in  the  case  of 
compression  of  the  inferior  cava  this  may  be  in  great  measure 
prevented  by  great  enlargement  of  the  vena  azj^gos.  It  must 
not  be  forgotten  also  that  the  epigastric  veins,  without  being 
at  all  enlarged,  may  be  rendered  more  visible  in  great  ascites 
owing  to  the  stretching  of  the  abdominal  walls  and  the  absorp- 
tion of  the  subcutaneous  fat. 

7.  There  is  little  or  no  pyrexia  and  no  tenderness  of  the 
abdomen,  except  over  the  liver. 

8.  Other  indications  of  the  existence  of  hepatic  disease, 
such  as  enlargement,  contraction,  nodulation,  or  tenderness  of 
the  liver,  jaundice,  flatulence,  &c.,  will  often  assist  the  dia- 
gnosis, but  you  must  remember  that  all  these  signs  may  be 
absent  or  indefinite. 

9.  The  fluid  obtained  by  paracentesis  is  a  clear,  straw- 
coloured  serum,  having  a  sjjecific  gravity  of  from  1012  to  1016, 
and  containing  a  large  quantity  of  albumen,  but  no  urea,  blood, 
nor  inflammatory  products. 

In  the  next  place  we  have  to  inquire  what  are  the  diseases 
of  the  liver  which  are  most  likely  to  occasion  ascites.  And 
first  it  must  be  remarked  that  there  are  some  morbid  conditions 
of  the  liver  which  very  seldom  give  rise  to  it.  The  fatty  liver  (see 
p.  48)  and  simple  hypertrophy  of  the  liver  (p.  58),  when  uncom- 
plicated, never  cause  it,  and  it  i-arely  results  from  mere  conges- 
tion (p.  133),  unless  this  depend  on  mechanical  obstruction  of 
the  circulation  in  the  chest.  Abscess  (pp.  165,  181)  and  hyda- 
tid tumour  (pp.  56,  102)  of  the  liver  do  not  lead  to  the  presence 


LECT.  XII.  DISEASES    OF    LIVER    OR    PORTAL    VEIN.  453 

of  fluid  in  tlie  peritoneum,  except  in  rare  cases,  from  tlie  direct 
pressure  of  the  tumour  on  tlie  trunk  of  tlie  portal  vein,  from 
the  bursting  of  the  cyst,  or  through  the  intervention  of  peri- 
tonitis. 

Fluid  in  the  peritoneum  is  a  more  common  accompaniment 
of  the  waxy  or  amyloid  liver  (p.  33)  than  of  any  of  the  maladies 
just  named,  but  even  here  it  is  rare.  Frerichs  noted  it  in  only 
8  out  of  23  cases,  and  in  4  of  the  8  cases  it  was  due  to 
the  supervention  of  acute  peritonitis.^  When  its  origin  is 
not  inflammatory,  it  is  probably  due  to  enlarged  waxy  lym- 
phatic glands  in  the  fissure  of  the  liver  pressing  upon  the  trunk 
of  the  portal  vein,  or  to  the  concurrence  of  peritonitis  or 
cirrhosis  (pp.  33,  47).  The  freedom  from  ascites  in  waxy  liver 
is  accounted  for  by  the  fact  that  it  is  the  branches  of  the 
hepatic  artery,  and  not  of  the  portal  vein,  which  are  impli- 
cated in  the  disease.  Fluid  in  the  peritoneum  from  waxy  liver 
will  be  recognised  by  the  following  characters  (see  also  p.  31)  t 

1.  Uniform  (but  in  very  rare  instances  nodulated,  pp.  32,  47), 
solid,  painless  enlargement  of  the  liver. 

2.  Enlargement  of  the  spleen. 

3.  A  large  quantity  of  albumen  in  the  urine,  with  little  or  no 
anasarca,  and  those  other  characters  of  the  urine  which  I  described 
to  you  in  my  lecture  on  waxy  enlargement  of  the  liver  (p.  34) .  Al- 
buminuria, however,  is  not  necessarily  present  in  cases  of  waxy 
disease.  Since  my  lecture  on  the  subject  was  delivered,  you 
have  seen  two  cases  in  the  wards,  where  there  was  considerable 
waxy  enlargement  of  both  liver  and  spleen,  but  where  the 
kidneys  were  so  slightly  implicated  that  the  urine  contained 
no  albumen. 

4.  Great  ansemia. 

5.  A  history  of  disease  of  the  bones,  or  joints,  suppurating 
sores,  phthisis,  or  constitutional  syphilis. 

The  diseases  of  the  liver  which  most  commonly  give  rise  to 
portal  obstruction  with  ascites  are  : 

1.  Cirrhosis  and  the  other  forms  of  interstitial  hepatitis. 

2.  Cancer  of  the  liver. 

3.  Peri-hepatitis. 

4.  Thrombosis  or  obstruction  of  the  trunk  of  the  portal  vein. 
Practically,  it  is  chiefly  with  the  two  first  that  you  will  have 

to  deal,  as  the  others  are  of  much  rarer  occurrence. 
'  Diseases  of  the  Liver.     Syd.  Soc.  Ed.  vol.  ii.  p.  179. 


454  FLUID    IN    THE    PEEITONEUM.  lbct.  xii. 

1.  Ascites  from  Interstitial  Hepatitis. 

Cirrhosis  and  the  other  forms  of  interstitial  hepatitis  are 
far  the  most  common  causes  of  portal  obstruction  leading  to 
ascites.  It  must  be  remembered  that  the  liver  in  these  cases 
is  not  necessarily  contracted,  and  that  in  fact  its  area  of  dul- 
ness  may  be  greatly  increased.  The  clinical  characters  of  as- 
cites from  interstitial  hepatitis  of  the  liver  are  as  follows : 

[See  antea,  pp.  139,  279.] 

2.   Ascites  from  Cancer  of  the  Liver. 

Cancer  of  the  liver  is  often  attended  by  fluid  in  the  peri- 
toneum, but  the  quantity  of  fluid  is  usually  small  as  compared 
with  what  is  observed  in  cirrhosis ;  while  the  liver  in  most 
cases  is  both  enlarged  and  nodulatedi  In  many  cases  the  as- 
cites has  an  inflammatory  origin  and  is  attended  by  pain, 
tenderness,  and  other  symptoms  of  peritonitis  during  life, 
while  the  fluid  in  the  peritoneum  contains  flakes  of  lymph, 
or  even  blood,  owing  to  rupture  of  the  capsule  covering  some 
of  the  deposits  of  cancer. 

The  liver  may  be  greatly  enlarged  from  the  presence  of 
isolated  nodules  of  cancer  without  any  ascites,  the  portal  cir- 
culation being  sufiiciently  maintained  by  the  healthy  glandular 
tissue  intervening  between  the  cancerous  nodules.  Ascites 
under  these  circumstances  is  only  produced  when  the  trunk  of 
the  portal  vein  is  compressed  in  the  portal  fissure  by  cancerous 
lymphatic  glands,  by  a  cancerous  outgrowtli  from  the  liver  itself, 
or  by  new  connective  tissue  resulting  from  peri-hepatitis  (see 
Case  LXXXVI.,  p.  218).  But  in  the  infiltrated  form  of  cancer 
the  ramifications  of  the  portal  vein  in  the  interior  of  the  liver 
are  destroyed  as  the  disease  advances,  and  hence,  when  this  is 
at  all  extensive,  there  is  almost  always  ascites. 

The  clinical  characters  of  ascites  from  cancer  of  the  liver 
are  as  follows : — 

[See  antea,  p.  208.] 

3.  Ascites  from  Peri-hepatitis. 

When  lymph  thrown  out  into  the  portal  fissure  becomes 
organised,  it  may  cause  constriction  of  the  trunk  of  the  portal 
vein,  and  all  the  phenomena  of  portal  obstruction.  As  a  rule 
this    development  of  new  connective   tissue  extends  over  the 


lEiCT.  XII.  DISEASES    OF    LIVER    OR    PORTAL    VEIN.  455 

entire  surface  of  the  liver  and  also  into  its  interior,  and  there 
is  developed  one  of  the  forms  of  interstitial  hepatitis  already 
referred  to.  Far  oftener,  peri-hepatitis  is  itself  secondary  to 
some  disease  of  the  liver  such  as  cirrhosis,  or  cancer.  When 
primary,  it  is  usually  of  syphilitic  origin.  According  to  Dr. 
Fagge,  at  Gny's  Hospital  there  is  one  fatal  case  of  ascites 
from  peri-hepatitis  for  every  five  of  dropsy  from  cirrhosis  ;  and 
the  urine  is  far  oftener  albuminous  in  the  former  malady  than 
in  the  latter.^ 

4.  Ascites  from  Thrombosis  or  Obstruction  of  the  Trunk  of  the 

Portal  Vein. 

Coagula  are  liable  to  form  in  the  portal  vein  and  obstruct 
its  passage  from  various  causes. 

a.  Disease  of  the  coats  of  the  vein  may  lead  to  coagula  in 
its  interior.  It  was  at  one  time  contended  that  coagula  here,  as 
in  other  parts  of  the  venous  system,  were  almost  always  the 
result  of  inflammation  of  the  venous  coats,  or  phlebitis,  but 
with  our  present  knowledge  it  is  doubtful  if  the  inflamma- 
tion of  the  venous  wall  (indicated  by  thickening,  adhesion  to  its 
contents,  etc.)  be  not  often  the  consequence  rather  than  the 
cause  of  the  coagulation.  There  are,  however,  a  considerable 
number  of  cases  on  record  where  calcification  of  the  wall  of 
the  portal  vein  has  converted  the  vein  into  a  rigid  narrow  tube, 
which  has  then  become  suddenly  blocked  up  by  coagulum. 
You  will  find  an  interesting  case  of  this  sort  reported  by  Dr. 
Andrew  Clark  in  the  Pathological  Transactions  (vol.  xviii. 
p.  61),  and  references  to  many  others  have  been  collected  by 
Frerichs.^ 

b.  Many  cases  of  thrombosis  of  the  trunk  of  the  portal 
vein  are  secondary  to  diseases  of  the  glandular  tissue  of  the 
liver,  which  obstruct  or  destroy  the  branches  of  the  vessel,  such 
as  the  various  forms  of  interstitial  hepatitis  and  infiltrated 
cancer.  The  obstruction  in  these  cases  commences  in  the 
ramifications  and  extends  to  the  trunk  of  the  vein. 

c.  Thrombosis  of  the  portal  vein  may  be  induced  by  com- 
pression of  the  vein  from  without  by  enlarged  cancerous  (pp. 
210,  454),  or  waxy  (pp.  33,  453),  or  tubercular  glands,  connec- 
tive tissue  from  old  peri-hepatitis  (pp.  276,  454),  outgrowths 
from  the  liver^  or  tumours  of  the  pancreas,  omentum,  etc.  If  the 

1  Guy's  Hosp.  Eep.  1875,  vol.  xx. 
-  Op.  cit.  Tol.  ii.  p.  402. 


456  FLUID    m    THE    PEEITONEUM.  LECT.  xii. 

compressinof  force  be  great,  tlie  vessel  may  be  flattened 
and  its  walls  brought  into  apposition  ;  more  commonly  the 
compression  acts  by  retarding  the  circulation  and  favouring 
coagulation. 

(/.  Lastly,  there  are  some  cases  of  thrombosis  of  the  portal  vein 
■which  seem  to  result  from  mere  weakness  of  the  circulation,  or 
from  an  unusual  disposition  of  the  blood  to  coagulate. 

The  symptoms  of  thrombosis  of  the  trunk  of  the  portal 
vein  are  those  already  described  to  you  (p.  279)  as  resulting  from 
obstruction  or  obliteration  of  the  ramifications  of  the  vessel  in 
chronic  atrophy,  but  in  an  exaggerated  form.     They  are : 

1 .  The  rapid  development  of  extreme  ascites,  often  necessi- 
tating paracentesis  to  avert  asphyxia,  and  returning  imme- 
diately after  the  operation. 

2.  Rapid  enlargement  of  the  veins  of  the  abdominal  wall, 
which  resemble  large  cords. 

3.  Urgent  vomiting  and  diarrhoea. 

4.  Copious  hsemorrhage  in  many  cases  from  the  stomach 
and  bowels.  Occasionally  this  is  the  first  and  chief  symptom, 
and  the  patient  dies  from  syncojse  before  there  is  time  for 
ascites  &c. 

5.  Great  enlargement  of  the  spleen. 

6.  Obstruction  of  the  trunk  of  the  portal  vein  in  most  cases 
is  speedily  fatal,  but  if  it  be  not,  it  leads  to  atrophy  of  the 
liver.'  A  contracted  liver  may  thus  be  either  the  cause  or  the 
consequence  of  portal  obstruction. 

I  have  thus  endeavoured  to  lay  before  you  succinctly,  and 
perhaps  somewhat  dogmatically,  the  distinguishing  characters 
of  fluid  in  the  peritoneum  according  to  its  several  causes.  In 
practice,  however,  you  must  remember  that  there  may  be  a 
concurrence  of  difl'erent  causes  in  the  same  case.  For  instance, 
I  have  more  than  once  pointed  out  to  you  that  portal  obstruc- 
tion may  be  secondary  to  obstruction  of  the  circulation  in  the 
heart  or  lungs,  and  I  have  also  shown  you  that  ascites  may 
result  from  either  of  these  causes  independently  of  the  other. 
Secondly,  although,  as  we  have  seen,  albuminuria  may  be 
induced  by  the  ascites  itself  (p.  282),  it  is  quite  possible,  and 
indeed  not  uncommon,  to  have  disease  of  the  kidneys  con- 
current with  portal  obstruction.     Spirit-drinking,  which  is  so 

'  See  for  instance  a  case  reported  by  Dr.  Dickinson  in  the  Pathological  Trans- 
ActiouB,  vol.  xiv.  p.  63. 


I.ECT.  XII.  TREATMENT.  45/ 

fruitful  a  source  of  cirrhosis  of  the  liver,  contributes  also  to 
the  development  in  many  cases  of  nephritis  and  of  the  fatty 
kidney.  Lastly,  thrombosis  of  the  trunk  of  the  portal  vein  is 
often  a  result  of  obstruction  of  the  ramifications  of  the  vessel 
in  the  interior  of  the  liver,  and  when  this  occurs,  the  symptoms 
of  slight  portal  obstruction  may  be  suddenly  succeeded  by  those 
of  complete  obstruction. 

The  Treatment  of  Fluid  in  the  Peritoneum. 

The  proper  treatment  for  any  case  where  there  is  fluid  in 
the  peritoneum  must  depend  entirely  on  the  cause  of  this 
condition,  and  you  will  therefore  perceive  the  necessity  which 
exists  of  being  able  to  recognise  the  cause,  or  the  predominant 
cause,  in  each  particular  case.  It  would  be  out  of  place  on  the 
present  occasion,  when  I  wish  to  direct  your  attention  mainly 
to  the  diseases  of  the  liver,  to  enter  into  a  consideration  of  the 
proper  treatment  for  the  various  maladies  that  may  give  rise  to 
fluid  in  the  peritoneum ;  and  I  have  already  described  to  you 
in  some  detail  the  appropriate  treatment  for  the  ascites  and 
other  symptoms  resulting  from  portal  obstruction.  It  is 
unnecessary  to  recapitulate  the  remarks  on  this  matter,  made 
in  my  lecture  on  Chronic  Atrophy  of  the  Liver  (p.  285). 

It  may,  however,  serve  to  impress  more  durably  on  your 
minds  the  remarks  which  have  now  been  made  on  the  distin- 
guishing characters  of  fluid  in  the  peritoneum  according  to  its 
several  causes,  and  also  the  rules  laid  down  in  my  systematic 
lectures  on  Medicine  for  the  treatment  of  the  various  maladies 
from  which  ascites  may  arise,  if  I  bring  under  your  notice  the 
particulars  of  a  few  cases  which,  with  three  exceptions,  you  have 
had  an  opportunity  of  watching  in  the  wards. 

Case  CXLYIII.  illustrated  at  first  the  points  of  distinction 
between  fluid  in  an  ovarian  cyst  and  ascites  or  fluid  in  the  perito- 
neum ;  but  subsequently  the  physical  signs  were  remarkably 
modified  by  the  entrance  of  air  into  the  ovarian  cyst.  A  mis- 
take in  diagnosis  was  all  the  more  likely  to  have  been  committed 
by  a  careless  observer  from  the  concurrence  of  albuminuria  and 
general  dropsy.  The  case  is  remarkable  from  its  rare  mode  of 
termination,  the  ovarian  cyst  opening  into  the  rectum.  No 
similar  case  is  reported  in  the  entire  series  of  the  Pathological 
Transactions  :  in  the  fourteenth  volume  (p.  201)  Dr.  Bristovve 
has  recorded  a  case  where  there  was  a  communication  between 


458  FLUID    IN    THE    PEEITONEUM.  lect.  xii. 

the  rectum  and  an  ovarian  cyst,  but  in  that  case  there  was 
extensive  tubercular  ulceration  of  the  bowel,  and  the  perfora- 
tion advanced  from  the  bowel  to  the  ovary.     In  the  case  of 

Elizabeth  C you  will  remember  that  Ave  were  enabled  to 

diagnose  not  merely  the  existence  of  the  ovarian  tumour,  but 
also  the  fact  of  the  cyst  having  burst  into  some  portion  of  the 
bowel.  After  removal  from  the  body,  the  walls  of  the  cyst 
collapsed  and  shrivelled,  so  that  no  adequate  idea  of  its  size  prior 
to  bursting  can  be  gathered  from  the  preparation  which  I  now 
show  you. 

Case  CXLYIII. — Cystic  Tumour  of  Ovary  opening  into  Rectum — 
Entrance  of  Air  into  Ovarian  Cyst — Atrophy  of  Bight  Lobe  of  Liver 
and  co7n'plenientary  Hypertrophy  of  Left  Lobe. 

Elizabeth    C ,  aged  37,  adm.  into  Middlesex  Hosp.  Ang.  23, 

1866.  Had  been  married  twice,  but  had  only  one  child,  still-born 
(1852),  and  never  any  miscarriages.  Catamenia  regular,  last  period 
having  ceased  day  before  admission.  At  age  of  16  had  been  laid  up 
for  six  weeks  with  scarlet  fevei',  but  did  not  know  if  she  had  dropsy. 
Ever  since  had  suffered  from  pain  in  back,  and  for  last  eight  years 
had  been  liable  to  general  dropsy  and  attacks  of  erysipelas  of  face." 
Eighteen  months  before  admission  had  first  noticed  a  swelling  in 
lower  part  of  abdomen,  which  had  been  slowly  increasing. 

On  admission  abdomen  considerably  distended  by  a  tumour  rising 
above  pubes  and  reaching  to  above  umbilicus.  This  appeared  to 
occupy  a  middle  position  in  abdomen,  but  could  be  traced  more  readily 
into  left  side  of  pelvis  than  into  right.  Tumour  was  dull  on  per- 
cussion and  distinctly  fluctuating;  behind  it,  in  either  flank,  percussion 
yielded  a  tympanitic  sound.  Both  lower  extremities  much  swollen, 
oedematous,  and  tender,  and  face  slightly  puffy.  Cardiac  and  respira- 
tory signs  normal,  but  arese  of  hepatic  and  splenic  dulness  increased. 
Urine  contained  a  considerable  amount  of  albumen,  and  deposited 
epithelial  and  oily  casts ;  sp.  gr.  1016.  Pulse  96  and  feeble ; 
occasional  vomiting.  On  Aug.  25  patient  began  to  have  dian-hoea; 
motions  contained  blood,  and  there  was  considerable  tenderness  of 
abdominal  tumour. 

On  Aug.  31  diarrhoea  continued  ;  no  pain  in  defalcation  ;  tongue 
clean  and  too  red ;  breath  very  offensive. 

On  Sept.  10  no  abatement  of  diarrha3a,  notwithstanding  free 
exhibition  of  astringents.  Tongue  dry  and  brown  and  breath  extremely 
off'ensive.  Patient  was  extremely  prostrate,  drowsy  (from  opium  ?  ), 
and  occa.sionally  delirious.  No  rigors  nor  sweating,  and  no  diminution 
in  size  of  tumour,  girth  of  abdomen  being  same  as  at  time  of  admission, 
(36  in.). 

On  Sept.  11  motions  contained  a  quantity  of  pus,  which  continued 


LECT.  XII.  ILLUSTRATIVE    CASES.  459 

to  be  passed  for  three  days,  and  on  Sept.  17  all  signs  of  tumour  had 
disappeared,  percussion  sound  above  pubes  being  equally  tympanitic  as 
in  flanks. 

After  this  little  diarrhoea,  but  patient  continued  to  sink,  and  died 
on  Sept.  19. 

At  atitopsy  a  thick  layer  of  fat  beneath  skin.  Heart  and  kings 
healthy.  Liver  weighed  53  oz. ;  right  lobe  much  atrophied  and  deeply 
lobulated,  but  left  lobe  enormously  increased,  being  nearly  three 
times  size  of  right ;  structure  appeared  healthy.  Spleen  weighed  20 
oz.  ;  very  firm,  and  presented  typical  characters  and  reaction  of  waxy 
degeneration.  The  two  kidneys  weighed  together  18^  oz. ;  both 
smooth,  pale-yellow  and  opaque ;  cortex  greatly  hypertrophied  and 
secreting  cells  loaded  with  oil.  On  first  opening  abdomen,  no  tumour 
visible ;  intestines  came  down  to  pubes  ;  but  on  raising  a  few  coils,  a 
collapsed  cyst,  about  size  of  a  cocoa-nut,  was  seen  in  situation  of  nterus. 
On  fiirther  examination,  this  was  ascertained  to  be  a  cyst  of  left  ovary, 
which  had  emptied  itself  by  an  opening,  size  of  a  fourpenny -piece,  into 
rectum  4  in.  above  anus  ;  its  walls  were  fibrous  and  about  half  an  inch 
thick,  and  it  contained  a  little  dirty,  very  fetid  pus.  Sigmoid  flexure 
of  colon  took  a  turn  transversely  to  right  side  across  upper  part  of 
tumour,  to  which  it  was  firmly  adherent ;  free  end  of  appendix  vermi- 
formis  also  adhered  to  it.  No  ulceration  of  mucous  membrane  of 
rectum  round  opening  into  ovarian  cyst. 

The  following  very  remarkable  case  illustrates  the  difi&culty 
in  diagnosis  which  may  arise  from  great  enlargement  of  the 
urina.ry  bladder.  In  a  female  the  physical  signs  would  have  at 
once  suggested  an  ovarian  tumour,  but  in  a  male  they  seemed 
only  explicable  on  the  supposition  of  a  hydatid  of  the  liver,  and 
it  was  with  this  view  that  the  surgeon  under  whose  care  the 
patient  was  had  recourse  to  paracentesis.  The  great  size  of 
the  swelling,  the  patient's  statement  that  it  commenced  above 
the  umbilicus,  the  fact  of  the  greatest  girth  of  the  abdomen 
being  3  in.  above  the  umbilicus,  and  the  complete  freedom  from 
urinary  symptoms,  suppressed  all  suspicion  of  the  bladder  being 
primarily  at  fault.  Such  a  case  is  not  likely  ever  to  occur  in  a 
female,  and  the  lesson  which  it  teaches  is  that  whenever  you 
find  the  physical  signs  which  were  present  in  this  case,  and  es- 
pecially when  they  occur  in  an  aged  male,  the  first  thing  to  be 
done  is  to  introduce  a  large  prostatic  catheter  into  the  bladder 
and  to  push  it  well  up.  It  is  worth  observing,  however,  that  in 
this  case  the  puncture  was  not  followed  by  any  extravasation 
of  urine  or  sign  of  peritonitis,  and  that  the  immediate  cause 
of  death  appeared  to  be  passive  haemorrhage  from  the  mucous 


460  FLUID    IN    THE    PEEITONEUM.  lect.  xil. 

membrane  of  the  bladder,  in  consequence  of  tbe  -witlidrawal  of 
the  urine. 

Case  CXLIX. — Enlargement  of  Ahdomen  from  a  distended  Urivary 
Bladder  tiiistalcen  for  a  Hydatid  Tumour  of  Liver — 480  oz.  of  Urine 
drawn,  off  by  Paracentesis  Abdominis. 

Mr.  F ,  a  feeble-looking  elderly  gentleman,  of  small  frame  and 

spare  habit,  consulted  an  eminent  surgeon,  to  whom  I  am  indebted  for 
these  particulars,  at  beginning  of  June  1866.  He  stated  tbat  until 
three  years  before  he  had  always  enjoyed  perfect  health  and  been  en- 
gaged in  active  pursuits.  He  then  first  noticed  a  swelling  above  the 
navel,  which  continued  to  increase,  but  caused  him  little  inconvenience 
until  beginning  of  previous  March,  when  his  breath  became  short  and 
he  began  to  lose  flesh  and  strength  and  to  get  nervous.  Early  in  May 
his  left  thigh  and  leg  became  swollen  and  pitted  on  pressure,  but  after 
two  weeks  swelling  disappeared.  For  several  weeks  he  had  been 
troubled  with  frequent  vomiting  after  food.  He  had  nevertheless  been 
able  to  ride  for  several  hours  a  day  up  to  time  of  his  presenting  him- 
self for  advice.  His  condition  was  then  noted  to  be  as  follows  : — '  He 
presents  appearance  characteristic  of  abdominal  disease.  Face  thin 
and  cadaverous,  but  not  jaundiced.  Abdomen  enormously  enlarged, 
being  occupied  by  a  tumour  of  uniform  surfece  and  oval  form,  of  which 
narrow  end  is  uppex'most.  Ensiform  cartilage  and  lower  ribs  on  both 
sides  elevated,  and  tumour  appears  to  spring  from  beneath  them  and 
to  fill  up  entire  anterior  portion  of  abdomen.  Fluctuation  is  distinct 
throughout  every  part  of  it,  but  is  particularly  marked  above  umbilicus. 
Tumour  is  everywhere  dull  on  percussion,  but  in  both  flanks,  in  what- 
ever posture  patient  assumes,  there  is  tympanitic  percussion-sound. 
Abdomen  is  largest  3  in.  above  umbilicus,  where  its  girth  is  43  in. ; 
distance  from  pubes  to  ensiform  cartilage  measures  21  in.  A  few  blue 
veins  are  seen  coursing  over  abdominal  wall.  Heart-sounds  weak,  but 
in  other  respects  normal.  Urine  abundant  ;  sp.  gr.  1010  ;  faintl}'  acid, 
and  with  a  slight  trace  of  albumen.  He  has  passed  water  three  or 
four  times  a  day,  and  once  during  night,  always  in  a  fiill  stream  and 
with  perfect  relief.'  Patient  always  insisted  that  he  had  never  suffered 
the  slightest  urinary  symptoms  nor  trouble  in  micturating,  but  subse- 
quently, after  bladder  had  been  tapped,  he  admitted  that  for  some  years 
he  hud  made  a  practice  of  sitting  down  when  he  made  water,  because 
ho  had  found  that  the  urine  '  came  better '  when  he  did  so. 

On  June  5  abdomen  was  tapped  with  a  fine  trocar  midway  be- 
tween umbilicus  and  ensiform  cartilage.  Twelve  quarts,  or  480  oz.,  of 
fluid  drained  away,  the  time  occupied  being  two  hours,  and  tumour 
slowly  disappearing.  The  fluid  was  of  a  pale  straw  colour  ;  sp.  gr.  1010, 
feebly  acid,  slightly  albuminous,  and  had  a  urinous  odour.  A  portion 
sent  to  me  for  examination  contained  urea  and  a  few  blood-corpuscles. 

June  6. — Patient  has   bad  a  comfortable  night,  but  has  passed  no 


LECT.  xir.  ILLUSTRATIVE    CASES.  46 1 

urine  since  operation.     Half  a  pint  of  darh  nrine  drawn  off  by  catheter 
in  morning,  and  1^  pint  in  evening.     Abdomen  is  again  large. 

June  7. — Has  bad  another  good  night  and  has  no  symptom  of  con- 
stitutional disturbance.  A  pint  and  a  half  of  dark  urine  was  drawn  off 
in  morning,  and  at  3  p.m.  six  pints  more,  and  as  this  flowed  away 
swelling  again  disappeared,  and  patient's  belly  became  quite  flat. 
Catheter  was  tied  in  but  soon  slipped  out.  During  the  hour  occupied 
in  emptying  bladder  patient  felt  very  faint,  and  soon  afterwards  he 
had  a  rigor  and  fainted  on  getting  up  to  try  to  micturate.  Stimulants 
were  given  freely  and  fainting  did  not  return,  but  he  had  a  restless 
night  and  vomited  several  times. 

June  8. — Urine  was  drawn  off  twice — morning  and  evenino- — and 
was  observed  to  contain  much  blood.  During  day  he  vomited  four 
times.     He  was  ordered  gallic  acid  and  ice. 

June  9. — Patient  much  weaker  and  urine  drawn  off  by  catheter  is 
almost  black  from  amount  of  contained  blood.  About  8  p.m.  he  passed 
into  a  state  of  collapse,  which  continued  until  death  at  3  a.m.  on 
June  10. 

Autopsy. — ]S"o  evidence  of  peritonitis.  Bladder  lay  collapsed  and 
flaccid  in  front  of  intestines,  filling  up  nearly  all  front  part  of  abdomen 
and  its  apex  being  within  l-l- in.  of  ensiform  cartilage.  The  reflexion 
of  peritoneum  from  bladder  to  abdominal  wall  was  within  1  in.  of  um- 
bilicus. A  small  red  spot,  like  a  flea-bite,  near  fundus,  corresponded 
to  puncture.  Bladder  contained  a  considerable  quantity  of  bloody 
urine  ;  muscular  coat  thir^kened  ;  mucous  membrane  thrown  into  promi- 
nent folds,  which  were  very  red  and  congested,  spaces  between  beino- 
pale.  Ureters  dilated  and  kidneys  sacculated:  in  left  kidney  very 
little  secreting  tissue  remained.  Prostate  enormously  enlarged,  almost 
filling  pelvic  cavity. 

The  next  case  occurred  in  my  own  practice.  It  is  similar 
to  tlie  last,  but  the  patient  was  young-er  and  made  a  good  re- 
covery, a  result,  I  believe,  rather  unusual  under  such  circum- 
stances. 

Case  CL. — Distended  Urinary  Bladder  mistalien  for  Ascites. 

On  March  3,  1876,  Mr.  Samuel  L ,  aged  46,  was   led  into  my 

consulting  room.  He  was  in  great  suffering,  and  I  was  informed  that 
two  homceopathic  doctors,  one  a  consultant  of  some  eminence,  had 
stated  that  he  was  suffering  from  disease  of  liver  and  dropsy,  and  that 
his  care  was  hopeless.  On  examination,  I  found  abdomen  greatly  dis- 
tended, girth  at  umbilicus  being  38g-  in.  ;  from  ensiform  cartilage  to 
navel  9  in.  and  from  navel  to  pubes  5-^  in.  The  swelling  was  evidently 
due  to  fluid,  which  was  encysted,  lying  in  front  of  bowels,  and 
rising  from  pelvis  to  within  an  inch  of  sternum.  Both  flanks  tym- 
panitic over  an  equal  extent  and  cyst  was  centi-al.     Patient  stated  that 


462  FLUID    IN    THE    PERITONEUM.  lect.  xii. 

for  many  years  be  had  had  a  stricture  of  urethra,  which  had  given  him 
no  trouble,  and  that  he  had  eujoj-ed  good  health  until  about  twelve 
months  before,  when  abdomen  began  to  swell  slowly.  Three  weeks 
before,  he  had  taken  a  cold  bath,  and  since  then  he  had  had  to  pass 
water  every  hour  and  had  some  difficulty  in  voiding  it.  Altogether, 
however,  he  passed  a  fair  quantity,  and  its  characters  were  normal. 
No  attempt  had  been  made  to  pass  a  catheter.  No  symptom  of  dis- 
ease of  liver. 

I  advised  that  patient  should  see  a  surgeon,  and  have  a  catheter 
passed  into  bladder.  This  was  not  done,  and  on  night  of  March  4  I 
was  sent  for  in  haste  to  see  patient,  as  he  was  believed  to  be  dying. 
At  my  suggestion,  Mr.  Berkeley  Hill  went  to  see  him,  provided  with  a 
suitable  instrument.  He  met  with  some  obstruction  at  neck  of  bladder, 
but  succeeded  in  drawing  off  7^  pints  or  150  oz.  of  clear  healthy  urine, 
and  in  producing  an  immediate  subsidence  of  the  abdominal  tumour. 
It  was  thought  better  not  to  empty  bladder,  but  a  bandage  was  applied 
round  abdomeu,  and  next  morning  5  pints  more  were  di*avvn  off. 

Patient  had  no  bad  symptoms;  a  catheter  was  passed  regularly 
twice  a  day  ;  on  March  15  he  was  going  on  well  and  had  returned  to 
business,  and  in  October  he  was  in  the  enjoyment  of  good  healtli,  and 
there  had  been  no  return  of  swelling. 

In  the  next  case  the  peritoneum  contained  fluid  as  the  re- 
sult of  acute  peritonitis. 

Oase  CLI. — Fluid  in  Peritoneum  from  Acute  Peritonitis  due  to  a  Kick 
over  a  Congenital  Hernia. 

Herbert  R ,  aged  12,  admitted  into   Middlesex  Hosp.  October 

28,  1866.  Since  four  years  of  age  he  had  been  known  to  have  an 
inguinal  hernia  on  right  side,  but  this  had  never  caused  him  much 
inconvenience :  and,  excepting  infectious  diseases  of  childhood,  he  had 
enjoyed  good  health  until  two  days  before  admission.  On  morning  of 
Oct.  26  he  received  a  kick  while  in  bed  over  right  testicle.  This  was 
followed  by  considerable  pain  in  testicle,  but  he  got  up  and  went  to 
school.  In  afternoon  he  had  a  rigor  lasting  for  half  an  hour,  followed 
by  diarrhoea,  and  later  in  evening  by  vomiting  and  pain  at  epigastrium, 
extending  thence  over  whole  abdomen.  During  whole  of  27th  and 
following  night  he  had  frequent  rigors  and  vomiting  and  urgent 
diarrhcxsa  witli  light-coloured  stools. 

On  admission,  puNe  144;  temperature  104°;  respirations  34  and 
thoracic;  abdomen  distended  and  extremely  tender,  especially  in  right 
groin;  right  testicle  much  enlnrged  and  exquisitely  tender ;  cardiac 
and  pulmonary  signs  normal.  IJoy  was  d(>af  and  confused  in  inind, 
like  a  patient  suffering  from  fever.  Poultices  with  laudanum  Avere 
a[)pliod  to  abdomen,  and  within  first  2 1>  hours  after  admission  patient 
took    as    much    as    5    gr.    of   opium    inlcrnally.       Under   this   ti'eat- 


LECT.  XII.  ILLUSTRATIVE    CASES.  463 

ment  acute  symptoms  subsided,  pain  and  vomiting  diminished  and 
diarrbcBa  ceased  ;  but  no  material  improvement  took  place.  Tongue 
became  dry  and  brown  ;  prostration  increased  ;  cheeks  were  sunken 
and  features  pinched  ;  and  there  was  occasional  delirium. 

On  Oct.  30  temperature  was  normal  (98^),  but  pulse  132  ;  abdomen 
more  distended,  and  distinct  evidence  on  tapping  of  fluid  in  peritoneum. 
Bowels  confined,  but  vomiting  had  returned.  On  Nov.  1  temperature 
still  98°,  but  no  improvement  in  patient's  general  condition. 

The  diagnosis  in  this  case,  as  frequently  stated  at  bedside,  was  that 
patient  was  suffering  from  acute  peritonitis  excited  by  kick  on  scrotum, 
inflammation  having  been  propagated  to  peritoneum  from  hernial  sac. 
It  was  suggested,  however,  by  a  gentleman  who  accompanied  me  on 
my  visits,  that  possibly  a  portion  of  bowel  had  become  strangulated  in 
neck  of  hernial  sac;  but  although  this  view  was  favoured  by  fact  that 
bowels  had  not  acted  since  boy's  admission,  the  bowels  had  been  very 
relaxed  previously  and  the  constipation  was  accounted  for  by  the  opium 
that  had  been  taken  subsequently.  One  of  my  surgical  colleagues, 
however,  who  at  my  request  saw  patient  in  my  absence,  thought  that 
probably  there  was  a  portion  of  bowel  or  omentum  strangulated  in  sac 
and  cut  down  upon  it.  A  little  pus  escaped,  but  none  of  intestinal 
contents  were  found  in  sac.  The  boy  gradually  sank,  and  died  at  8  A.M. 
on  following  morning. 

Autopsy. — Chief  morbid  appearance  was  very  extensive  recent 
peritonitis,  sui'face  of  liver  and  whole  of  bowels  being  plastered  over 
with  soft  yellow  lymph. '  Peritoneum  also  contained  two  or  three  pints 
of  purulent  fluid.  N^o  ulceration,  perforation,  nor  gangrene  of  any 
portion  of  stomach,  bowel,  or  appendix  vermiformis,  to  account  for  peri- 
tonitis. No  bowel  nor  omentum  in  hernial  sac,  nor  even  adherent  in 
neighbourhood  of  internal  opening.  Intense  vascular  injection  of  outer 
surface  of  right  testicle. 

In  the  following  case  fluid  was  thrown  out  into  the  a.bdo- 
inen  as  the  result  of  sub-acute  peritonitis.  But  the  chief 
pathological  interest  of  the  case  lay  in  the  fact,  that  the  appear- 
ances found  in  the  liver  after  death  corresponded  in  every  way 
with  those  which  have  been  so  often  described  of  late  years 
as  constituting  one  of  the  lesions  of  constitutional  syphilis  (see 
pp.  141,  276),  and  yet  that  the  evidence  was  as  strong  as 
negative  evidence  can  well  be  in  such  a  matter,  against  the 
view  that  the  patient  had  ever  suffered  from  syphilis. 

Case     CLII. — Fluid  in  Peritoneum  from  Chronic  Feritonitis — Chronic 
Atrophy  of  Liver  with  Fibroid   (probably  syphilitic)  Nodules  in  its  in- 
terior. 
P.  D ,  aged  67,  admitted  into  Middlesex  Hosp.  Jan.  17,  1867. 

He  was  a  labourer,  had  been  married  for  23  years,  and  was  the  father 


464  FLUID    IN    THE    PERITONEUM.  lect.  xii. 

of  seven  cliildren.  His  oldest  child  was  22  ;  all  were  in  good  health, 
and  none  had  died  ;  his  wife  had  never  had  any  miscarriages.  A  brother 
had  died  of  consumption,  but  patient  himself  had  always  enjoyed  good 
health,  except  for  about  three  months  three  or  four  years  previously, 
during  which  time  he  had  been  in  hospital  for  a  fractui'e  of  arm  and 
other  injuries.  He  had  never  had  rheumatic  fever,  dropsy,  jaundice, 
vomiting,  nor  haemorrhoids,  aiid  denied  syphilis.  His  habits  had  been 
temperate.  Six  weeks  before  admission  a  heavy  weight  fell  upon  his 
head,  which  wounded  scalp  and  stunned  him  for  a  few  seconds.  For 
four  days  after  this  he  gave  up  his  work,  and  complained  of  pain  iu 
region  of  liver.  On  fifth  day  he  returned  to  work,  but  after  a  few 
hours  he  was  obliged  to  give  it  up.  A  week  after  accident  he  noticed 
that  abdomen  was  swelling,  and  a  fortnight  after  he  began  to  vomit 
his  food  as  soon  as  it  was  swallowed.  Between  this  date  and  that  of 
admission  he  had  become  very  emaciated. 

At  time  of  admission  patient  was  greatly  emaciated,  and  coun- 
tenance  was  expressive  of  suffering.  Tongue  moist  and  coated  with  a 
yellowish  fur  ;  no  appetite,  but  patient  complained  of  thirst,  although 
he  was  afraid  to  drink,  as  everything  he  took  was  rejected  within  a 
quarter  of  an  hour.  He  distinctly  stated,  however,  that  he  had  no 
pain  between  swallowing  and  vomiting.  Abdomen  considerably  dis- 
tended, girth  at  umbilicus  measuring  33^  in.  ;  unmistakable  evidence 
of  fluid  in  peritoneum.  Hepatic  dulness  in  right  mammary  line 
measured  only  3  in. ;  no  jaundice.  Splenic  dulness  not  increased  ;  no 
enlargement  of  subcutaneous  veins  of  abdomen.  Immediately  above 
and  below  umbilicus  an  obscure  induration,  with  no  defined  margin, 
and,  at  some  parts,  yielding  clear  percussion.  Abdomen  generally 
tender,  but  by  no  means  acutely  so ;  fair  movement  of  abdominal  muscles 
in  respiration.  Patient  stated  that  he  was  not  in  much  pain,  but 
he  seemed  to  be  always  easier  when  lying  on  back  with  legs  drawn 
up.  Bowels  regularly  open.  Pulse  96  and  regular;  cardiac  dulness 
less  than  natural ;  sounds  normal.  Respirations  2G  ;  coarse  crepitus 
over  bases  of  both  lungs,  without  any  dulness  or  tubular  breathing. 
Not  the  slightest  oedema  of  legs,  trunk,  nor  face,  and  urine  free  from 
albumen. 

All  efforts  to  relieve  vomiting  proved  unavailing.  Size  of  abdomen 
remained  stationary.  On  Jan  20  hiccough  cnme  on,  and,  notwith- 
standing frequent  exhibition  of  nutritions  enemata,  emaciation  ra])idly 
increased  until  Jan.  28,  when  patient  died  from  exhaustion. 

At  autopsy,  one  gallon  of  turbid  fluid  in  abdominal  cavity  in  front 
of  small  intestines,  which  were  firmly  matted  together,  forming  a 
globular  mass  ])ointing  towards  umbilicus  and  accounting  for  obscure 
tumour  felt  during  life.  Peritoneum  was  everywhere  coated  with  a 
thick  layer  of  reticulated  lymph  and  great  omentum  much  thickened 
and  indurated,  but  nowhere  about  bowels  nor  mesenteric  glands  was 
any  indication  of  tubercular  or  cancerous  deposit.     Stomach  much  con- 


LECT.  xti.  ILLUSTRATIVE    CASES.  465 

tracted,  and  mucous  tnembratie  for  several  inches  from  pylorus  reddened 
and  thrown  into  folds  and  under  microscope  presented  a  remarkably 
villous  appearance ;  pyloric  end  surrounded  and  pressed  on  by  greatly 
thickened  omentum,  but  nowhere  in  its  coats  could  any  appearance  or 
structure  resembling  that  of  cancer  be  discovered.  Liver  small,  weighing 
only  40  oz. ;  capsule  at  some  places  thickened  and  adherent  to  surround- 
ing parts,  and  over  surface  were  several  cicatrix-like  depressions. 
Scattered  through  substance  of  liver  were  numerous  rounded  opaque- 
yellow  deposits,  largest  about  size  of  a  cherry.  Such  of  deposits  as 
were  immediately  beneath  capsule  were  not  at  all  raised  above  general 
surface,  while  otbers  were  situated  at  bottom  of  cicatrix-like  depressions. 
On  section  they  presented  a  firm,  fibrous-looking  appearance,  and 
yielded  no  milky  juice.  On  microscopic  examination  they  were  found 
to  be  made  up  of  white  fibrous  tissue,  with  nuclei  and  small  fibre-cells 
and  granular  matter,  but  to  contain  nothing  suggestive  of  cancer. 
Spleen  small ;  lungs  congested  and  oedematous  at  bases ;  kidneys 
slightly  granular ;  heart  small,  but  healthy.  IS'o  deposits  like  those 
in  liver  could  be  found  in  any  other  organ,  and  no  cicatrices  could  be 
discovered  on  penis,  in  groins,  or  on  legs. 

The  three  following  cases  were  good  examples  of  fluid  in 
the  peritoneum  due  to  cancerous  peritonitis. 


Case  CLIII. — Primary  Cancer  of  Peritoneum,  causing  a  large  JEffusion 

of  Fluid. 

Jane  A ,  aged  51,  nurse  in  a  private  family,  was  admitted  into 

King's  College  Hospital  under  my  care  on  July  22, 1859.  Her  general 
health  had  always  been  good  prior  to  illness  for  which  she  was  admitted. 
She  had  never  had  any  other  illness  of  importance,  and  had  always 
lived  comfortably  and  been  temperate  in  her  habits.  No  hereditary 
tendency  to  cancer  could  be  ascertained.  Three  months  before  ad- 
mission she  began  to  complain  of  pain  in  lower  part  of  belly,  in  situa- 
tion of  left  ovary  and  of  bladder,  and  also  in  back.  The  pain  above 
pubes  was  always  worse  after  micturition.  She  was  thought  to  have 
inflammation  of  bladder  ;  leeches  were  applied  and  pain  abated.  Still 
she  kept  at  work  until  a  fortnight  before  admission,  when  she  was 
seized  somewhat  suddenly  with  febrile  symptoms,  vomiting,  much 
pain  and  tenderness  of  abdomen,  followed  by  swelling,  which  rapidly 
increased. 

On  admission,  patient  emaciated,  but  abdomen  greatly  distended, 
measuring  3G|^  in.  at  umbilicus,  and  presenting  all  the  characters  of  fluid 
in  peritoneum  with  addition  of  great  tenderness  on  pressure,  especially 
on  left  side.  Pulse  92  ;  tongue  very  red  and  clean  ;  bowels  constipated, 
but  easily  acted  on  by  medicine  ;  and  occasionally  much  vomiting. 
No  enlargement  of  liver   or  spleen,  and  no  jaundice  ;  no  anasarca  of 

H  H 


)466  FLUID    IN    THE    PERITONEUM.  lect.  xii. 

legs  ;  heart's  sounds  normal ;  urine  scanty  and  dark,  but  contained  no 
albumen. 

Treatment  consisted  in  effervescing  draughts  with  hydrocyanic 
acid  to  allay  sickness,  a  diuretic  pill  containing  squill,  digitalis,  and 
blae-pill,  and  colocynth  and  henbane  pills  to  keep  bowels  open.  At 
first  diuretics  increased  flow  of  urine,  and  size  of  abdomen  remained 
stationary  ;  but  about  middle  of  August  they  seemed  to  lose  their 
effect,  abdomen  became  larger,  while  tympanitic  portion,  which  always 
was  uppermost  in  whatever  position  patient  lay,  became  smaller.  On 
Aug.  27  abdomen  measured  40  in.  in  circumference,  and  patient 
complained  much  of  its  feeling  very  tight  and  painful  ;  respirations 
38  and  thoracic,  and  much  dyspnoea  from  pressure  of  fluid  on  diaphragm ; 
nothing  abnormal  in  physical  signs  of  lungs.  Tongue  still  very  red 
and  clean  ;  vomiting  more  frequent  and  urgent ;  bowels  never  opened 
without  medicine  From  first  she  had  continued  losing  fle.sh,  and  her 
features  were  now  pinched,  and  she  slept  little.  To-day  abdomen  was 
tapped,  and  about  two  gallons  of  a  transparent  greenish-yellow  fluid, 
having  a  specific  gravity  of  1020  and  containing  much  albumen  and 
also  many  white  flakes  of  fibrillated  lymph,  were  drawn  off.  For  two 
days  afterwards  patient  experienced  great  relief ;  sickness  and  pain 
ceased.  No  tumour  could  be  felt  in  abdomen  after  evacuation  of  fluid. 
On  morning  of  Aug.  30  patient  was  seized  with  severe  vomiting 
and  a  return  of  pain  and  tenderness  in  abdomen,  which  was  much 
distended  and  tympanitic,  while  at  same  time  there  was  evidence  of  a 
small  quantity  of  fluid  in  peritoneum.  Vomiting,  emaciation,  and  ab- 
dominal pain  continued,  uninfluenced  by  treatment.  Patient  could 
bear  nothing  in  her  stomach  except  champagne  and  ice,  and  for  four 
weeks  she  was  nourished  by  enemata  of  beef-tea,  eggs,  and  brandy, 
with  a  few  drops  of  laudanum.  Aphthte  appeared  on  tongue.  Fluid 
did  not  reaccumulate  in  large  quantity  in  abdomen,  but  early  in  Sep- 
tember several  small  nodules  could  be  felt  through  abdominal  parietes. 
On  Sept.  18  left  thigh  and  leg  were  noted  to  be  swollen,  and  there 
was  tenderness  along  course  of  femoral  vein.  After  this  patient  was 
thought  on  several  occasions  to  be  moribund  ;  but  she  rallied,  to  die  at 
last  on  Sept.  28,  in  a  state  of  extreme  emaciation. 

Autops)/. — Only  30  oz.  of  clear  straw-coloui'cd  fluid  were  found 
in  the  peritoneum.  The  peritoneal  surface  of  all  the  intestines,  of  the 
liver,  and  of  the  bladder,  were  studded  over  with  innumerable  nodules 
of  cancer,  varying  in  size  from  a  pin's  head  to  a  hazel-nut.  The 
mesenteric  glands  were  also  slightly  enlarged  from  cancerous  deposit. 
The  cancerous  masses  exuded  a  milky  juice  on  section,  which  contained 
characteristic  '  cancer-cells.'  The  intestines  were  connected  here  and 
there  by  a  few  loose  adhesions,  and  the  sigmoid  flexure  was  firmly 
bound  down  over  the  iliac  vein  by  firmer  adhesions  and  nodules  of 
cancer.  There  was  no  cancer  of  the  mucous  or  muscular  coats  of  the 
Btomach  or  bowels,  or  in  the  uterus,  liver,  kidueys,  or  lungs ;  in  the 


LECT.  xii.  ILLUSTRATIVE    CASES.  467 

apex  of  the  right  lung  were  several  cretaceoTis  nodules.  The  liver  and 
spleen  were  of  normal  size.  The  left  iliac  and  femoral  veins  were 
plugged  by  adherent  coagula. 

Case  CLIV. — Cancerous  Peritonitis  and  Tumour  of  Omentum. 

Catherine   H ,    38,    charwoman,   adm.   into    Middlesex    Hosp. 

Jan.  16,  1869.  Father  died  at  78  of  '  old  age '  ;  mother  (40)  and  two 
sisters  (39  and  40)  died  of  consumption ;  one  sister  alive  and  well. 
No  history  of  cancer  in  family.  Excepting  occasional  cough,  patient 
had  enjoyed  good  health  till  12  weeks  before  admission,  when  she 
began  to  complain  of  fulness  and  tension  of  stomach  after  eating,  and 
after  four  weeks  she  was  attacked  with  shivering,  severe  lancinating 
pain  in  abdomen  and  back,  and  occasional  vomiting.  A  month  before 
admission  vomiting  became  more  urgent  and  abdomen  began  to  swell, 
and  swelling  increased  so  rapidly  that  paracentesis  had  been  proposed 
to  relieve  dyspnoea.  With  these  symptoms  were  constipation,  scanty 
nrine,  and  emaciation,  but  no  night-sweats.  A  tumour  had  also  been 
detected  between  umbilicus  and  pubes. 

State  on  admission. — Emaciated,  with  anxious  expression,  but  no 
jaundice  nor  dilatation  of  capillaries  of  face.  Complains  of  severe  pain 
and  swelling  of  abdomen,  which  measures  at  umbilicus  33-|  in.  and 
presents  distinct  signs  of  fluctuation,  and  at  same  time  is  extremely 
tender,  so  that  slightest  tapping  causes  intense  suffering.  The  pain  is 
constant,  but  subject'  to  exacerbations.  Hepatic  dulness  does  not 
ascend  too  high.  No  enlargement  of  abdominal  veins  nor  of  spleen. 
Between  umbilicus  and  pubes  is  a  distinct  central  hard  tumour,  and 
on  vaginal  examination  Dr.  Hall  Davis  reports,  '  uterus  generally  en- 
larged, probably  from  carcinomatous  disease.'  Tongue  moist,  slightly 
furred,  rather  too  red  ;  frequent  retching  ;  bowels  costive.  Pulse  108, 
feeble ;  no  abnormal  sound  over  heart.  Respirations  60,  entirely 
thoracic  ;  lungs  liealthy.     Urine  1024  ;  no  albumen. 

Patient  was  ordered  a  grain  of  opium  every  eight  hours  and 
laudaumn  fomentations  to  abdomen.  By  this  treatment  pain  and 
vomiting  were  for  a  time  relieved,  but  on  Jan.  21  pain  again  so  severe 
that  it  was  necessary  to  have  recourse  to  subcutaneous  injections  of 
morphia,  and  by  Feb.  11  as  much  as  one  grain  of  morphia  was  injected 
three  times  a  day.  On  Jan.  26  slight  pitting  of  legs  ;  on  28tb,  tongue 
dry,  red,  and  smooth,  with  aphthous  patches.  On  Feb.  19  patient  was 
seized  with  acute  pain  in  left  side  of  chest,  over  which:  pleuritic  friction 
and  crepitation  audible.  Abdominal  swelling  did  not  increase  much, 
but  exhaustion  and  emaciation  were  daily  more  marked,  until  at  length 
patient  sank  and  died  on  Feb.  27. 

Autopsy. — Abdomen  only  examined.  Peritoneum  contained  several 
pints  of  bloody  serum.  Inner  surface  of  abdominal  wall  was  coated 
with  a  rough  layer  of  recent  lymph,  and  intestines  and  mesentery 

H  H  2 


468  FLUID    IN    THE    PERITONEUM.  lect.  xii. 

studded  with  numerous  small  nodules  of  cancer,  some  larger  tban  a 
pea.  Tumour  felt  during  life  was  not  uterus,  but  a  mass  of  cancerous 
deposit  in  omentum. 

Case  CLV. — Cancerous  Peritonitis. — Tumour  of  Omentum. — Double 

Pleurisy. 

Mary  Ann  P ,  48,  adm.  into  Middlesex  Hosp,  March  9,  1871. 

Father  (47),  one  brother,  one  sister,  and  two  of  her  own  children  had 
died  of  consumption.  Mother  died  at  46 ;  for  three  months  before 
death  had  jaundice  and  enlargement  of  liver  (cancer  ?)  Married  and 
had  seven  children  and  one  miscarriage  ;  catamienia  ceased  two  years 
ago.  For  several  years  had  a  winter-cough,  and  during  last  12  months 
had  lost  flesh  and  often  perspired  profusely  at  night  Eleven  weeks 
before  admission  became  very  weak  and  lost  appetite,  and  after  four 
or  five  days  began  to  have  sour  eructations  after  food  as  well  as  at 
other  times.  Six  weeks  before  admission  began  to  suffer  from  pain  in 
epigastrium  and  left  side  of  abdomen  and  about  right  shoulder-blade. 
Two  weeks  later  abdomen  began  to  swell,  and  a  fortnight  before  ad- 
mission swelling  was  first  observed  in  legs.  Bowels  had  been  costive  ; 
night-sweats  had  ceased  when  abdomen  began  to  swell. 

State  on  admission. — Very  weak  and  emaciated  ;  slight  oedema  of 
legs.  Complains  of  pain  and  swelling  of  abdomen,  which  measures  at 
umbilicus  34  in.  Has  all  signs  of  fluid  in  peritoneum.  In  left  side  of 
abdomen  a  hard  swelling  also  felt  extending  from  under  left  ribs  down- 
wards and  forwards  to  2  in.  below  level  of  umbilicus,  smooth,  with  no 
sign  of  splenic  notch,  and  not  tender.  Liver  cannot  be  felt.  Ab- 
dominal veins  enlarged.  Pain  commences  at  epigastrium,  and  stretches 
down  to  left  side  and  up  to  right  shoulder  ;  it  often  comes  on  suddenly 
and  severely,  quite  irrespectively  of  taking  food,  and  lasts  for  about  20 
minutes.  No  jaundice.  Tongue  clean  ;  appetite  bad  ;  often  vomits 
food  within  half  an  hour,  and  most  solid  food  causes  pain  until  it  is 
rejected.  Pulse  84  ;  sounds  of  heart  healthy.  Frequent  loose  cough 
with  mucous  expectoration ;  considerable  dyspnoea ;  mucous  niles 
heard  over  both  lungs,  most  abundant  on  left  side.  Temp.  101  ••5°. 
Sleeps  fairly.  Urine  1019  ;  alkaline ;  no  albumen,  no  bile-pigment 
and  no  lithatcs. 

Patient  was  ordered  a  mixture  of  quinine,  iron,  and  spirit  of 
nitrous  ether,  with  wine.  At  first  she  improved ;  vomiting  ceased  ; 
pain  was  relieved ;  she  was  able  to  eat  and  retain  meat ;  and  abdomen 
gradually  diminished  until  on  March  24  girth  of  abdomen  was  only 
29  in.  ;  no  sign  of  fluid  in  peritoneum  could  be  detected  and  there  was 
no  oedema  of  l(!gs.  Splenic  dulnoss  could  now  be  separated  by  a 
tympanitic  space  1^  in.  in  breadth  from  tumour,  and  finger  could  be 
inserted  between  upper  border  of  this  and  lower  left  ribs.  No  bowel 
could  be  made  out  in  front  of  tumour,  and  there  was  tympanitic  per- 
cussion note   behind  it.      On  vaginal  examination   tumour    did   not 


LECT.  XII.  ILLUSTRATIVE    CASES.  469 

appear  to  have  any  connection  with  uterus  or  ovaries.  Notwithstand- 
ing these  signs  of  improvement,  attacks  of  pain  became  more  severe, 
so  that  on  March  31  it  was  necessary  for  first  time  to  have  recourse 
to  morphia,  and  on  April  12  abdomen  was  covered  with  belladonna 
and  glycerine.  On  April  26  there  was  again  fluid  in  peritoneum,  and 
abdomen  measured  32  in.  ;  and  on  April  28  patient  vomited  for  first 
time  since  admission.  On  May  1,  increased  dyspnoea  with  lividity  of 
lips,  and  over  lower  third  of  both  lungs  dullness  with  feeble  breathing. 
CEdema  of  legs  bad  also  returned.  No  pyrexia.  A  pill  of  digitalis, 
squill,  blue  pill,  and  morphia  twice  daily  was  now  ordered.  On  May 
5  abdomen  measured  33  in.,  and  there  was  dulness  with  feeble  breathing 
over  lower  half  of  both  lungs.  Vomiting  now  became  frequent,  and 
on  May  15  diarrhoea  (4  stools  daily)  set  in.  Abdomen  again  became 
reduced  until  on  May  29  girth  was  only  29  in.,  but  patient  became 
rapidly  weaker  and  died  on  May  31. 

Autopsy. — Four  pints  of  turbid  flaky  serum  in  peritoneum.  Loose 
bauds  of  adhesion  passed  from  abdominal  parietes  through  fluid  to  intes- 
tines, which  were  bound  by  adhesions  into  a  rounded  mass.  Peritoneal 
coat  of  bowels  intensely  congested  and  studded  with  numerous  opaque 
white  deposits  of  cancer.  Tumour  felt  during  life  in  left  side  of  ab- 
domen consisted  of  omentum  greatly  thickened  by  cancerous  infiltra- 
tion and  fibrous  tissue,  and  lying  in  front  of  left  kidney  and  descend- 
ing colon.  Both  ovaries  about  size  of  small  oranges,  and  made  up  of 
soft  cancerous  matter  with  cysts  containing  a  gelatinous  fluid.  Liver 
small,  rounded,  and  firm  ;  its  capsule  greatly  thickened,  at  some  places 
to  extent  of  2  or  3  lines.  Kidneys  healthy.  Heart  healthy.  Right 
pleura  contained  22  oz.,  and  left,  44  oz.  of  turbid  serum.  Both  lungs 
condensed  and  carnified,  and  outer  surface  of  both  coated  with  rough 
membrane  or  lymph,  which  could  be  readily  peeled  off.  No  deposit  in 
either. 

In  tlie  two  next  cases  there  was  a  considerable  accumulation 
of  fluid  in  the  peritoneum  due  to  tubercular  peritonitis.  Case 
CLVI.  resembled  two  of  the  cases  of  cancerous  peritonitis  in  the 
fact  that  there  was  an  omental  tumour ;  while  Case  CLVII.  was 
remarkable  in  the  disappearance  of  the  fluid  and  the  recovery 
of  the  patient  under  treatment. 


Case  CLVI. — Fluid  in  Peritoneum  from  Tubercular  Peritonitis — Tuhercle 
of  Omentum  and  Paracentesis — Death. 

Charles  A ,  28,  India-rubber  worker,  adm.  into  St.  Thomas's 

Hosp.,  May  25,  1876.  Father,  mother,  and  five  brothers  and  sisters 
alive  and  healthy  ;  4  brothers  and  sisters  died  in  infancy ;  no  phthisis 
in  family.  Excepting  '  bilious  attacks,'  had  good  health  till  two  years 
ago ;  since  then  had  drank  a  good  deal  of  beer  and  spirits,  and  had 


470  FLUID    IN    THE    PERITONEUM.  lect.  xu. 

complained  of  palpitations  and  dyspnoea.  Six  weeks  ngo  coughed  tij) 
a  little  blood  on  several  occasions.  Three  weeks  ago  began  to  have 
pain  across  upper  part  of  abdomen,  with  nausea,  anorexia,  and  oc- 
casional vomiting  of  viscid  mucus,  especially  in  morning.  Bowels 
also  became  relaxed ;  6  or  8  dark  brown  liquid  motions  in  day. 
Worked  till  day  before  admission. 

On  admission,  pale  and  thin ;  no  jaundice  nor  stellate  veins  on 
cheeks.  Abdomen  much  distended,  measuring  35  in.  at  umbilicus. 
Great  tympanitic  prominence  between  umbilicus  and  ensiform  carti- 
lage ;  also  considerable  ascites.  Upper  margin  of  hepatic  dulness 
rose  to  within  half  an  inch  of  nipple  ;  lower  margin  conld  not  be  made 
out.  Spleen  not  large.  No  appreciable  tumour.  No  tenderness  of 
abdomen,  but  considerable  pain  at  times  across  upper  part.  Diarrhoea 
persisted,  but  vomiting  had  ceased.  No  cough  ;  no  abnormal  signs  in 
lungs.  P.  108  ;  sounds  of  heart  normal.  Temp,  at  night  rose  to 
102°  or  103°.     Urine  1020,  high-coloured  ;  no  albumen. 

Patient  was  treated  with  diuretics  and  a  nutritious  diet,  and  sub- 
sequently with  quinine  and  mineral  acids.  Diarrhoea  persisted,  and 
fluid  in  abdomen  increased.  On  June  7  girth  37^  in.,  much  pain  in 
abdomen  and  some  dyspnoea.  Nine  pints  of  fluid  were  drawn  ofi"  by 
paracentei-is  ;  this  was  of  a  greenish  colour,  alkaline  and  clea.',  but 
contained  flakes  of  fibrillated  lymph  entangling  blood-cells  ;  sp.  gr. 
1020.  After  this,  breathing  was  relieved  and  fluid  did  not  collect 
again  to  any  extent.  But  he  continued  to  get  thinner,  and  about 
June  12  he  complained  much  of  cough,  and  bronchitic  rales  wer(^ 
heard  over  both  lungs.  During  June  he  had  occasional  hectic  flusli 
on  cheeks  ;  evening  temp,  varied  from  99'4°  to  101'5°  ;  no  decided 
night-sweats.  On  July  1  girth  at  umbilicus  only  31  in.  ;  an  obscure 
induration  could  be  felt,  apparently  in  the  omentum,  stretching  fi'om 
umbilicus  to  left  ribs  ;  its  position  not  affected  by  deep  inspiration. 
After  this,  emaciation  rapidly  increased,  and  indurated  mass  could  be 
felt  extending  across  upper  part  of  abdomen  to  right  ribs  ;  cough 
became  more  frequent,  and  there  wt.s  expectoration  of  viscid  mucus 
which  gradually  became  puriform.  Diarrhoea  persisted  and  vomiting 
returned  ;  but  at  no  time  were  there  night-sweats.  Death  by  exhaus- 
tion on  July  31. 

Antojisy. — Peritoneum  contained  six  pints  of  clear  yellow  serum, 
part  of  which  was  contained  in  separate  cavities  bounded  by  lym])h. 
Great  omentum  everywhere  infiltrated  with  a  thick  firm  tubercular 
mas3,  adherent  to  the  parietal  peritoneum  and  to  the  intestines. 
Serous  covering  of  bowels  studded  with  small  nodules  of  tubercle, 
and  glued  by  soft  lympli  to  one  another  and  to  surrounding  parts  ; 
two  small  tubercular  ulcers  in  ileum.  Liver  somewhat  enlarged  and 
fatty.  Small  deposits  of  tubercle  becoming  caseous  in  centre  scattered 
through  both  lungs,  and  in  upper  part  of  left  lung  larger  niasses  of  soft 
caseous  tubercle  breaking  down  into  cavity.     Apex  of  left  lung  firmly 


LECT.  xii.  ILLUSTRATIVE    CASES.  4/1 

adherent  and  marked  by  cicatricial  depressions ;  16  oz.  of  sernm  in 
left  pleura,  and  4  oz.  in  right.     Heart  and  other  organs  healthy. 

Case     CLVII. — Fluid     in    Peritoneum   from    Tubercular    Peritonitis. 
Recovery  under  treatment. 

On  Feb.   18,  1876,  I  saw  in   consultation  with  Mr.  A.  Maclaren, 

Miss  M ,  aged  21.     She  had  always  been  delicate,  and  in  previous 

autumn  had  been  laid  up  four  or  five  v^eeks  with  pleurisy  on  left  side. 
About  four  weeks  before  I  saw  her,  first  noticed  her  abdomen  enlarg- 
ing, with  some  pain  but  not  at  all  severe,  and  since  then  she  had  been 
getting  thinner  and  weaker  and  sh.e  had  perspired  during  sleep.     On 
examination    abdomen   was   tense   and    evidently   contained   a   small 
quantity  of  fluid,  but  was  not  tender.     Girth  at  umbilicus  32  in.     N'o 
sign  of  tumour.    Tongue  coated  ;  appetite  fair  ;  no  nausea  nor  retching  ; 
bowels  confined.     Pulse  108.     Temp.  101°  to  103°.     No  cough  ;  but 
dulness,  flattening,  and  crepitation  below  left  clavicle.     Urine  scanty 
and  dark.     Patient  was  ordered  quinine  and  iron  in  conjunction  with 
digitalis.     On  Feb.  23  already  felt  better ;  urine  more  copious  ;  abdo- 
men less  tense ;  girth   31  in. ;  pulse  84 ;  temp.   99°  to   102'5°.     Feb. 
28 :   Girth  29^  in.  ;  pulse  60  and  irregular  ;  temp.  98-6°-101-5°     Still 
feels  better  ;  to  continue  iron  and  quinine,  but  to  omit  digitalis.     The 
digitalis  was  resumed  from  time  to  time,  and  patient  also   took  iodide 
of  potassium  and  syrup  of  iodide  of  iron  and  cod  liver  oil.      On  March 
13,  girth  28^  in. ;  pulse  64 ;  temp,  had  not  exceeded  100°  at  any  time 
during  a  week.     On  March  20,  girth  27  in.,  no  sign  of  fluid  in  abdo- 
men ;  intestines  feel  matted  together ;  temp.  99°.     April  10  :    There 
has  been  no  rise  of  temperature,  and  continues  to  improve ;  intestines 
still   feel   matted ;    still   dulness   at  left  apex,  but   no  moist   sounds. 
After  this  patient  continued  to  improve,  and  remained  well  all  summer  ; 
but  in  October  I  heard  that  she  was  again  laid  up  with  fever  and  signs 
of  mischief  in  right  lung. 

Case  CLVIII.  appeared  to  be  one  of  those  already  referred  to 
(p.  444),  where  a  quantity  of  fluid  collects  in  the  peritoneumj  a,s 
the  result  of  a  subacute  inflammatory  process. 

Case  CLVIII. — Ascites — Ancemia.     (Tubercle  ?) 

Martha  W -,  aged  11,  adm.  into  Middlesex  Hosp.  July  17,  1868. 

Father  died  of  phthisis  ;  mother  living  and  healthy  ;  one  sister  living 
and  healthy  ;  no  brothers.  Some  years  before  had  measles  and  whoop- 
ing cough.  Last  spring  had  a  cough  and  expectoration  for  some  months, 
but  ho  night-sweats.  Cough  got  better,  but  about  a  month  before 
admission  abdomen  began  to  swell,  followed  after  three  days  by  rather 
severe  diarrhoea  and  loss  of  flesh.  Eight  days  before  admission 
patient  was  tapped  1^  in.  below  the  umbilicus,  and  8  pints   of  clear 


472  FLUID    IN    THE    PEEITONEUM.  lect.  xn. 

transparent  fluid  drawn  off.  Three  or  four  days  after  tapping  diarrhoea 
subsided. 

On  admission,  child  was  thin  and  anaemic ;  abdomen  distended  with 
fluid,  measuring  24J  in.  at  umbilicus.  No  CBdema ;  no  evidence  of 
disease  of  heart  or  kidneys  ;  no  enlargement  nor  pain  of  liver.  Pulse 
120  ;  no  pyrexia  nor  night-sweats.  Tongue  clean  ;  appetite  good  ; 
bowels  quiet ;   some  prolapsus  ani. 

A  good  diet  and  perchloride  of  iron  with  spirit  of  nitrous  ether 
were  prescribed.  Under  this  treatment  ascites  slowly  diminished,  and 
by  Aug.  15  all  trace  of  it  had  disappeared  ;  girth  of  umbilicus  was  only 
21^  in.,  and  general  health  seemed  good. 

The  next  case  was  a  remarkable  one.  Notwithstanding  the 
unusual  degree  of  tenderness,  the  slow  pulse,  the  low  tempera- 
ture, and  the  paroxysmal  character  of  the  pain  led  us  to  regard 
the  case,  in  the  first  instance,  as  merely  one  of  severe  colic.  Its 
pathology,  however,  was  prohably  similar  to  that  of  the  last 
case. 

Case  CLIX. — Symptoms  of  Colic  followed  by  signs  of  Fluid  in 
Peritoneum. 

Edward  J ,  aged  21,  who  had  formerly  been  a  printer,  but  had 

been  working  for  six  weeks  at  a  carver  and  gilder's,  was  admitted  into 
Middlesex  Hospital  April  12,  1868.  On  April  G  he  had  been  suddenly 
seized  with  severe  pain  in  abdomen  and  retching.  Pain  had  been  con- 
stant ever  since,  but  had  been  liable  to  severe  exacerbations  ;  vomiting 
had  recurred  daily,  but  had  not  been  so  violent  as  at  first.  Bowels  had 
acted  on  8th  and  10th  after  castor  oil  and  laudanum.  Shortly  before 
attack  patient  had  been  sufi'ering  from  gonorrhoea,  and  he  stated  that 
some  years  before  he  had  a  similar,  though  much  less  severe,  attack  of 
abdominal  pain. 

On  admission  patient  still  complained  of  constant  pain  in  abdomen, 
with  frequent  acute  exacerbations  ;  pain  was  increased  by  any  move- 
ment, and  there  was  also  considerable  tenderness  over  abdomen,  most 
marked  over  the  caecum.  Abdomen  distended  and  tympanitic,  and 
breathing  entirely  thoracic  ;  frequent  retching  of  scanty  bilious  matter. 
A  dark  red  (not  blue)  line  along  margin  of  gums ;  tongue  moist  and 
only  slightly  furred;  thirst ;  bowels  had  not  been  open  for  two  days. 
Pulse  84 ;  skin  cool ;  temperature  under  tongue  97°;  no  albumen  in 
urine. 

Patient  was  ordered  a  warm  bath,  warm  fomentations  to  belly,  an 
enema  of  three  pints  of  barley-water  with  four  drachms  of  tincture  of 
assafoetida,  and  a  grain  of  opium  every  four  hours.  Enema  brought 
away  two  copious  motions,  but  Avith  no  relief  to  pain.  On  April  13  a 
third  of  a  grain  of  extract  of  belladonna  was  ordered  every  three  hours, 


LECT.  XII.  ILLUSTRATIVE    CASES.  473 

but  next  day  pain,  tenderness,  and  tension  of  abdomen  bad  increased, 
althougb  pulse  was  only  72,  and  temperature  97°.  He  was  again 
ordered  a  grain  of  opium  every  four  hours,  a  draught  of  castor  oil  and 
laudanum,  and  frequent  enemata.  He  continued  taking  six  grains  of 
opium  a  day  until  April  17,  and  then  three  grains  until  April  23.  Under 
this  treatment  Vowels  were  freely  moved,  and  paroxysms  of  pain  less 
severe  ;  but  he  still  had  occasional  vomiting,  abdomen  grew  larger  and 
more  tense,  and  on  April  19  there  was  unmistakable  evidence  of  fluid, 
in  peritoneum.  A  thrill  could  be  propagated  from  one  side  to  the 
other  on  tapping,  and  when  patient  was  supine  there  was  dulness  in 
either  flank,  which  varied,  with  his  posture.  He  still  had  occasional 
paroxysms  of  pain,  but  no  tenderness  of  the  abdomen.  Pulse,  however, 
kept  steadily  at  72,  and  temperature  rarely  exceeded  98°.  Signs  of 
fluid  in  peritoneum  with  occasional  slight  paroxysms  of  pain  con- 
tinued until  May  4.  After  this  abdomen  gradually  became  smaller, 
and  on  May  18  it  had  regained  its  normal  size  and  presented  no  sign 
of  fluid,  and  patient  left  hospital  free  from  pain. 

Case  CLX.  w^as  a  good  illustration  of  fluid  in  the  perito- 
neum resulting  from  disease  of  tlie  kidneys.  During  life  the 
case  was  regarded  as  an  example  of  the  large  white  kidney 
following  nephritis  and  passing  into  the  fatty  kidney ;  and  al- 
though one  of  the  kidneys  was  unexpectedly  found  very  con- 
tracted after  death  from  some  old  disease,  you  will  observe  that 
the  other  has  three  times  the  size  and  weight  of  a  normal 
kidney. 

Case  CLX. — Fluidin  Peritoneum  from  disease  of  Kidney — Albuminuria 
and  General  Anasarca — Pericarditis  and  Pleurisy — Death  by  Urcemia 
— Great  Hypertrophy  of  Left  Kidney  and  Atrophy  of  Right. 

James    S ,  aged   23,  was  admitted  into   Middlesex   Hospital 

March  12,  1868.  Excepting  an  attack  of  '  gastric  fever  '  2^  years 
before,  his  previous  health  had  been  good.  He  had  never  suffered  from 
scarlet  fever  ;  but  for  nine  years  he  had  been  in  habit  of  working  in  a 
very  hot  room,  and  of  drinking  gin  as  well  as  beer  daily.  Six  weeks 
before  admission  he  went  from  the  West  End  to  the  City  one  evening 
and  got  wet  through.  Three  nights  after  this,  on  taking  off"  his  boots 
he  noticed  that  feet  were  swollen,  and  next  morning  there  was  slight 
swelling  of  legs,  thighs,  trunk,  and  even  efface.  He  continued  work- 
ing for  two  or  thi^ee  days  and  then  went  to  St.  Bartholomew's 
Hospital,  where  he  remained  a  month,  but  got  worse  rather  than 
better.  Four  or  five  days  before  coming  to  hospital  he  found  his 
breath  becoming  short. 

On  admission  the  patient's  countenance  extremely  anemic,  pasty 
and  puffy  ;  considerable  cedematous  swelling  of  trunk,  extremities,  and 


474  FLUID    IN    THE    PERITONEUM.  lect.  xii. 

scrotum.  Pulse  84 ;  cardiac  dulness  slightly  increased  and  sounds 
feeble  but  otherwise  normal.  Over  lower  fourth  of  both  lungs  dulness 
on  percussion,  with  faint,  distant,  vesicular  breathing,  and  coarse  crepi- 
tation. Liver  and  spleen  appeared  to  be  of  normal  size  ;  no  jaundice 
nor  tenderness  of  abdomen,  but  unmistakable  evidence  of  fluid  in  peri- 
toneum. Tongue  thickly  coated ;  occasional  vomiting  after  food ; 
bowels  regular.  Urine  scanty  and  smoky  and  contained  a  large 
quantity  of  albumen  {-^  in  volume) ;  it  deposited  a  sediment  in  which 
were  numerous  blood-corpuscles  and  a  few  granular  and  oily  casts,  but 
no  hyaline  nor  epithelial  casts.      Slight  pain  on  pressure  over  kidneys. 

Patient  was  treated  with  warm  baths  and  hot  air-baths,  dry  cupping, 
sinapisms  and  poultices  to  loins  ;  drastic  purgatives,  such  as  compound 
jalap  powder,  salts  and  senna,  and  subsequently  elaterium  ;  perchloride 
of  iron,  with  large  doses  of  liquor  ammonije  acetatis  ;  and  subsequently 
diuretics,  such  as  acetate  and  bitarti-ate  of  potash  with  digitalis. 

At  first  there  was  slight  improvement,  but  anasarca  and  amount  of 
fluid  in  serous  cavities  gradually  increased.  From  April  1  to  April  8 
a  double  pericardial  friction-sound  was  heard  over  heart,  and  on  its 
cessation  cardiac  dulness  was  noted  as  measuring  four  inches  (instead 
of  two)  transversely,  and  cardiac  sounds  very  feeble.  On  April  8 
urine  became  almost  solid  on  boiling.  On  April  11  dulness  had  ex- 
tended over  lower  half  of  both  lungs,  and  there  was  orthopncea. 
Ascites  had  also  increased.  On  April  11  patient's  countenance  heavy 
and  stupid ;  memory  slightly  confused ;  he  was  very  restless  at  night 
and  vomited  occasionally.  On  April  13  and  14  urine  was  noted  as 
depositing  numerous  rounded  corpuscles  distended  with,  oil,  about 
-^J-jj^  in.  in  diameter,  and  very  like  compound-granular  corpuscles  seen 
in  softened  brain-tissue.  On  April  15  there  had  been  no  action  of 
bowels  and  no  urine  passed  for  24  hours  ;  4  oz.  of  urine  drawn  off 
by  catheter  became  almost  solid  on  boiling.  Tongue  dry  and  brown  ; 
breath  very  ofiensive,  and  mind  confused.  On  same  evening  patient 
had  a  slight  attack  of  convulsions  followed  by  coma,  which,  notwith- 
standing sinapisms  to  nape  and  feet,  croton  oil  internally,  and  hot-air 
baths,  continued  until  death,  on  morning  of  17th. 

Autopsij. — Brain  anaemic ;  about  an  ounce  of  clear  serum,  contain- 
ing much  urea,  in  lateral  ventricles  and  at  base.  Nearly  a  pint  of 
tnrl)id  serum  in  pericardium.  Surface  of  heart  coated  with  a  rough 
loosely  adherent  layer  of  lymph  ;  heart  large,  weighing  19  oz. ;  great 
hypertrophy  of  left  ventricle,  but  valves  all  competent  and  healthy. 
Each  pleura  contained  about  a  pint  of  clear  serum,  and  lower  lobe  of 
left  lung  coated  with  a  thin  layer  of  recent  lymph  ;  lungs  extremely 
oodematous.  Peritoneum  contained  several  pints  of  clear  serum. 
Liver,  spleen,  and  mucous  membrane  of  stomach  all  extremely  con- 
gested. Left  kidney  greatly  enlarged  and  weighed  lh\  oz. ;  surface 
was  smooth  and  capsule  not  adherent;  cortex  greatly  hypertrojjhied, 
measuring  at  some  places  ^  in.  between  base  of  a  pyramid  and  outer 


LECT.  xiT.  ILLUSTRATIVE    CASES.  475 

surface  ;  pjTamids  congested,  but  cortex  pale  ;  renal  tubes  gorged 
with  epitheliam-cells,  most  of  which  very  granular,  and  many  loaded 
with  oil ;  large,  globular,  compound-granular  corpuscles,  like  those 
passed  in  ui-ine  during  life,  in  interior  of  some  of  tubes.  Right  kidney 
very  small,  and  weighed  only  1^  oz. ;  surface  granular  and  capsule 
adherent ;  cortex  dense  and  atrophied  ;  some  of  renal  tubes  atrophied  ; 
others  contained  granular  or  fatty  epithelium,  or  compound-granular 
bodies.  Right  ureter  not  obstructed  nor  pelvis  dilated ;  right  renal 
artery  pervious,  but  became  suddenly  contracted  to  ime-half  at  about 
its  middle. 

Case  CLXI.  was  an  example  of  ascites  from  interstitial 
hepatitis,  which  was  secondary  to  valvular  disease  of  the  heart 
(see  also  p.  146). 

Case  CLXI. — Constriction  of  Mitral  Valve — Chronic  Atrophy  of  Liver — 
Ascites  and  Jaundice. 

Mary  T ,  aged  61,  was  admitted  into  Middlesex  Hospital  Feb. 

24,  1868.  For  twenty  years  she  had  been  liable  to  winter-cough,  and 
for  fifteen  years  she  had  suffered  from  palpitations  and  dyspnoea  on 
exertion.  Three  years  before  admission  dyspnoea  increased,  and  after 
a  year  legs  began  to  swell,  and  she  was  laid  up  on  this  account  for 
three  months.  After  another  year  she  first  noticed  swelling  of  abdo- 
men, which,  as  well  as'swelling  of  legs,  increased  slowly.  She  stated 
that  she  had  never  had  rheumatic  fever,  but  that  for  several  years  she 
had  suffered  from  pains  in  her  limbs  and  also  from  attacks  of  diarrhoea. 
Catamenia  had  ceased  at  age  of  30.  Several  weeks  before  admission 
skin  had  become  yellow. 

On  admission,  patient's  countenance  anxious ;  lips  and  cheeks 
livid  ;  great  oedema  of  both  lower  extremities  with  tension  of  integu- 
ments ;  also  considei'able  oedema  of  left  arm,  but  no  pufiiness  of  face 
nor  swelling  of  riglit  arm.  Abdomen  greatly  distended  with  fluid  in 
peritoneum,  measuring  at  umbilicus  39  in.  Pulse  120,  small  and 
feeble,  but  regular ;  apex  of  heart-beat  between  fifth  and  sixth  ribs, 
slightly  to  left  of  left  nipple  ;  transverse  cardiac  dulness  increased, 
measuring  3  in.,  increase  being  mainly  to  left;  over  point  of  impulse 
a  prolonged  pre-systolic  bellows-murmur.  Respirations  40,  and 
embarrassed  ;  frequent  cough,  with  expectoration  of  puriform  mucus ; 
bronchitic  rales  audible  over  greater  part  of  both  lungs,  and  over 
lower  half  of  both  posteriorly  coarse  crepitation  and  feeble  breathing. 
Tongue  moist  and  furred  ;  great  thirst  and  no  appetite  ;  frequent 
vomiting  after  food  ;  tenderness  at  epigastrium  ;  bowels  open  three 
or  four  times  in  night  before  admission.  Hepatic  dulness  much 
diminished,  not  exceeding  two  inches  in  r.  m.  1. ;  decided  icteric  tinge 
of  skin  and  conjunctivas  and  distinct  reaction  of  bile-pigment  in  urine, 


4/6  FLUID    IN    THE    PERITONEUM.  LECT.  xii. 

wliich  was  scanty,  but  contained  no  albumen.     Mind  clear  ;  slept  very 
badly,  owing  to  ortboj^noea. 

Patient  was  treated  with  diuretics  (nitrous  etber,  acetate  of  potash, 
and  decoction  of  broom-tops,  with  a  pill  of  digitalis,  blue  pill  and 
squill),  and  stimulants  (gin  8  oz.  and  brandy  4oz.),  while  mustard  and 
linseed-poultices  were  applied  over  chest.  Prostration  and  dyspnoea 
nevertheless  increased.  On  Feb.  26  pulse  86,  extremely  feeble  and 
irregular ;  respirations  48,  but  interrupted  by  frequent  cough  ;  expecto- 
ration consisted  of  nummular  masses  of  yellow  pus  ;  veins  of  neck 
turgid,  with  slight  regurgitation  from  below.  Bowels  had  acted  six 
or  seven  times  in  night.  Dropsy  had  increased,  and  right  hand  and 
arm  now  oedematous.  These  symptoms  continued  until  patient's 
death  at  midnight  between  Feb.  27  and  28. 

A'utojisij. — Heart  weighed  14  oz.  ;  mitral  orifice  much  constricted, 
just  admitting  tip  of  finger,  and  flaps  of  valve  very  rigid  and  thickenc^d 
from  fibrous  and  calcareous  deposit ;  also  calcareous  deposit  in  aortic 
valves,  which,  however,  were  competent ;  tricuspid  orifice  slightly 
dilated.  Firm  adhesions  between  opposed  surfaces  of  both  pleurae ; 
pulmonary  pleuree  thickened  ;  and  lower  part  of  both  lungs  condensed 
from  intersecting  fibrous  bands,  with  cedema  and  congestion  of  inter- 
vening pulmonary  tissue ;  bronchial  tubes  dilated,  walls  thickened, 
and  interior  filled  with  pus.  Peritoneum  contained  several  quarts  of 
yellow  serum.  Liver  very  small  and  dense,  with  much  fibrous  deposit 
on  its  surface  and  also  extending  into  its  interior ;  outer  surface  at 
several  places  granular,  the  depressions  corresponding  to  centre  of 
lobules;  liver  weighed  only  31  oz.  Mucous  membrane  of  stomach 
intensely  injected,  with  much  adherent  mucus  and  numerous  ha>raor- 
rhagic  erosions.      Kidneys  slightly  granular. 

Although  in  the  following  case  the  patient  on  three  different 
occasions  recovered,  so  that  fortunately  no  opportunity  was 
afforded  for  verifying  our  diagnosis,  there  was  little  doubt  that 
the  fluid  in  the  peritoneum  was,  as  in  several  eases  which  I 
brought  under  your  notice  in  former  lectures  (Lect.  IV.  and 
VIII.),  due  to  portal  obstruction  from  cirrhosis  of  the  liver. 


Case  CLXII. — History  of  Splrit-drmldnri — Cirrhosis  of  Liver — Enlarged 
Spleen  —  Ascites —  G astro-enteritis  —  Epistaxis  and  Hcematemesis  — 
liemuval  of  Ascites  by  Diuretics  and  other  remedies  on  three  different 
occasions. 

Etienne  D ,  aged  39,  a  pipe-maker,  was  admitted  into  Middlesex 

Hosp.  under  my  care  on  A[)ril  23,  1868.  His  mother  was  alive,  aged 
76  ;  but  his  father  at  61,  and  a  brother  at  28,  had  died  from  cflects 
of  hard  drinking.     Patient  himself  had  for  many  years  been  in  habit 


LECT.  xii.  ILLUSTRATIVE    CASES.  47/ 

of  drinking  largely  of  beer  and  spirits,  especially  the  latter,  and  for 
last  three  years  he  bad  been  very  intemperate,  taking  large  quantities 
of  brandy  and  rum. 

Although  he  had  never  had  an  attack  of  delirium  tremens,  he  had 
often  been  very  shaky  in  morning.  !N^otwithstanding  his  habits,  he 
had  enjoyed  good  health  until  three  years  before  admission,  when  he 
began  to  suffer  about  every  week  or  ten  days  from  severe  pinching 
pains  in  abdomen  followed  by  cliarrhcea,  which  was  checked  by  chalk- 
mixture.  Nine  months  before  admission  he  began  to  retch  in  morning 
three  or  four  times  a  week,  and  twelve  months  before  admission  he 
had  an  attack  of  bleeding  piles.  During  last  year  also  gums  had  been 
liable  to  bleed,  and  he  had  been  losing  flesh.  Five  weeks  before 
admission  vomiting  became  more  urgent,  and  he  began  to  suffer  from 
attacks  of  acute  twisting  pain  in  right  side  of  abdomen.  A  fortnight 
later  vomiting  subsided,  but  diarrhoea  came  on,  and  he  first  noticed 
abdomen  begin  to  swell ;  this  swelling  rapidly  increased  and  duringr 
last  week  had  caused  much  dyspnoea.  He  continued,  however,  drink- 
ing port  wine  and  brandy  and  water  until  admission. 

State  on  admission  was  as  follows  : — Body  spare,  with  sharp 
features  ;  face  sallow  ;  distinct  icteric  tint  of  conjunctivse,  but  no 
evident  jaundice  of  trunk  or  extremities  ;  capillaries  of  face  much 
enlarged  ;  no  pnflBness  of  face  nor  anasarca  of  extremities.  Chief 
complaints  are  of  great  weakness  and  of  swelling  and  pain  in  abdomen, 
which  is  not  tender,  but  is  much  distended  and  measures  34  in.  at 
umbilicus.  Enlargement  is  evidently  due  to  fluid  in  peritoneum. 
Abdominal  veins  unusually  distinct  and  slightly  enlarged,  especially 
in  cspcal  region,  where  they  form  a  distinct  network  connected  with 
the  veins  ascending  to  chest.  Hepatic  dulness  in  r.  m.  1.  cannot 
be  made  out  distinctly.  In  epigastrium  liver  can  be  felt  through 
abdominal  parietes  ;  it  is  hard  and  resisting,  without  any  appreciable 
nodulation.  Splenic  dulness  increased,  measuring  vertically  -i  in.  and 
extending  forwards  to  within  2^  in.  of  line  of  nipple.  Tongue  coated 
with  a  thick  yellow  fur  ;  appetite  iadifferent  ;  bowels  open  about  four 
times  a  day  ;  motions  watery  and  yellow.  Pulse  108  ;  physical  signs 
of  heart  and  lungs  normal.  Urine  acid;  sp.  gr.  101";  free  from 
albumen,  but  contains  a  small  quantity  of  bile-pigment. 

Patient  was  ordered  a  draught  four  times  a  day  containing  acetate 
of  potash  (gr.  xx),  spirit  of  nitrous  ether  (5ss),  and  decoction  of 
broom-tops  (^jss)  ;  and  a  pill  twice  a  day  wdth  squill  (gr.  jss), 
powder  of  digitalis  (gr.  ss),  and  blue  pill  (gr.  iij).  An  ointment  com- 
posed of  equal  parts  of  blue  ointment  and  ung.  belladonnae  was  applied 
over  abdomen.  Alcohol  in  every  shape  was  interdicted,  and  diet  was 
restricted  to  milk,  beef-tea,  and  farinaceous  articles.  No  attempt  was 
made  to  check  diaiThcea.  He  at  once  began  to  improve.  He  had 
frequently  colicky  pains  in  abdomen,  and  on  May  2,  3,  6,  and  7  he  had 
attacks   of  vomiting,  and  on  May  7  slight  epistaxis.     But  from  first, 


478  FLUID    IN    THE    PERITONEUM.  lect.  xii. 

flow  of  urine  increased  and  ascites  diminished,  as  shown  by  following 
measurements  : — 

Girth  at  umbilicus,  April  23,  34  inches. 

27,83-6    „ 

May  4,  31-75  „ 

6,  30-75  „ 

11,  29-25  „ 

22,  28-25  „ 

On  May  22  patient  was  greatly  better.  Abdomen  of  natural  size  ; 
no  evidence  of  ascites.  Purging  and  vomiting  bad  ceased  ;  the  appe- 
tite improved,  and  he  could  eat  and  retain  meat.  Splenic  dulness  was 
reduced,  and  hepatic  dulness  in  right  mammary  line  measured  3^  in., 
apparent  increase  in  latter  being  probably  due  to  its  lower  margin 
being  no  longer  obscured  by  bowels  distended  with  gas.  In  epigas- 
trium liver  could  be  felt  hard  and  obscurely  nodulated. 

On  June  22  he  left  hospital,  without  any  return  of  dropsy  and 
gaining  flesh. 

After  leaving  hospital  he  gradually  returned  to  his  former  habits 
of  drinking  largely  of  beer  and  spirits.  But  with  exception  of 
occasional  epistaxis  and  an  attack  of  diarrhoea  in  summer  of  1869, 
he  had  fair  health  until  beginning  of  March  1870,  when  he  began  to 
suffer  from  great  nausea,  retching  in  morning,  pain  and  tenderness 
in  hepatic  region,  and  swelling  of  abdomen.  About  end  of  May  legs 
began  to  swell,  breathing  became  embarrassed,  and  once  he  vomited 
about  a  pint  of  blood.  On  June  30  he  was  again  admitted  into 
Middlesex  Hospital  under  my  care. 

Chief  symptoms  were  these : — Face  sallow,  much  itching  of  skin, 
but  no  jaundice ;  frequent  retching,  but  does  not  vomit  food,  and 
appetite  good ;  tongue  unusually  smooth,  devoid  of  papillae  and  red ; 
2  loose  motions  in  day.  Girth  at  umbilicus  34^  in. ;  considerable 
ascites;  liver  large  and  firm,  but  smooth;  hepatic  dulness  in  r.  m.  1. 
5|  in.  and  lower  edge  2|  in.  below  ribs ;  no  obvious  enlargement  of 
spleen.  Much  tense  oedema  of  legs.  Urine  clear  and  containing  a 
trace  of  bile-pigment,  but  no  albumen.  Pulse  76 ;  heart-sounds 
normal.  Respiration  embarrassed,  but  no  signs  of  oedema  of  lungs, 
nor  of  fluid  in  pleura.  Bismuth  and  a  milk  diet  were  first  given  to 
allay  sickness,  and  afterwards  treatment  consisted  in  pills  of  blue  pill, 
squill  and  digitalis,  a  mixture  of  perchloride  of  iron  and  nitrous  ether, 
and  occasional  saline  aperients.  He  again  speedily  improved,  and  on 
July  28  he  left  hospital,  with  a  good  appetite,  no  retching  and  no 
appreciable  ascites,  girth  at  umbilicus  being  32  in.,  but  no  diminution 
in  size  of  liver. 

On  March  12,  1873,  patient  was  admitted  a  third  time  into 
T^Iiddlesex  Hosp.  under  Dr.  H.  Thomson  with  similar  symptoms  to 
those  of  his  two  former  attacks,  but  with  addition  of  general  bronchitis 


LECT.  XII.  ILLUSTRATIVE    CASES.  479 

and  fibroid  (?)  consolidation  of  right  lung.  Liver  now  extended  to  an 
incli  below  umbilicus,  and  its  sarface  was  distinctly  nodulated.  He 
again  left  hospital  on  May  29,  much  better.  Some  months  after 
leaving  hospital,  dropsy  returned,  with  large  sloughing  sores  on  legs, 
under  which  patient  sank.     There  was  no  post-mortem  examination. 

Ill  a  former  lecture  (Lect.  YI.)  I  have  called  your  attention 
to  cases  of  ascites  resulting  from  cancer  of  the  liver.  In  the 
following  case  ascites  without  jaundice  was  produced  by  com- 
pression of  the  portal  vein  by  a  mass  of  cancerous  glands  in  the 
portal  fissure,  just  as  we  have  found  jaundice  with  or  without 
ascites  produced  by  a  similar  cause  (Lect,  X.). 

Case  CLXIII. — Cancer  of  Stomach  and  Omentum — Cancerous  Glands 
cam-pressing  Portal  Vein  and  causing  Ascites — Cancerous  Nodules  in 
Abdominal  Parietes. 

Charlotte  H ,   54,   adm.  into  Middlesex  Hosp.  March  5,  1869. 

Father  lived  to  84  ;  mother  and  two  grown-up  sisters  dead  ;  cause  un- 
known. Excepting  a  winter-cough  for  six  years,  patient  had  enjoyed 
good  health  until  early  in  December  1868,  when  she  began  to  suffer 
from  pain  in  upper  part  of  abdomen,  vomiting  after  food,  and  great 
prostration,  with  loss  of  appetite  and  flesh.  About  same  time  she 
noticed  abdomen  and  legs  begin  to  swell. 

State  on  admission. — Great  prostration  and  vertigo ;  marked 
aneemia;  moderate  oedema  of  both  legs.  Abdomen  greatly  distended 
by  fluid  in  peritoneum,  but  not  tender  ;  no  appreciable  tumour,  and 
no  obvious  enlargement  of  liver,  but  beneath  skin  of  abdominal 
parietes  were  several  firm  nodules,  about  size  of  peas.  Tongue  clean ; 
appetite  bad  ;  bowels  open  ;  no  vomiting,  but  much  pain,  after  food. 
Pulse  108 ;  arteries  rigid  ;  first  sound  of  heart  at  base  somewhat  pro- 
longed. Lungs  healthy.  Urine  1026  ;  much  lithates,  but  no  albumen. 
Some  numbness  of  left  arm,  and  indistinctness  of  speech. 

After  admission,  vomiting  returned  in  an  urgent  form.  Bismuth, 
creasote  and  opium,  and  blisters  with  morphia  dressing  failed  to  give 
relief.  Vomited  matters  were  dark  green.  Pain  at  epigastrium  per- 
sisted. Brandy  and  beef-tea  injections  were  administered,  but  patient 
rapidly  sank  and  died  on  March  14. 

Autopsy. — Six  pints  of  clear  serum  in  peritoneum.  At  pylorus  was 
a  large  soft  cancerous  tumour  extending  4  in.  into  stomach,  its  inner 
surface  deeply  excavated  by  ulceration,  so  as  to  form  a  cavity  com- 
municating above  with  stomach,  and  below  with  duodenum.  Extensive 
cancerous  deposit  in  glands  of  lesser  omentum,  one  mass  as  large  as  a 
hen's  egg  compressing  portal  vein.  Post-peritoneal  glands  in  front  of 
vertebral  column  also  enlarged  from  cancer,  forming  a  mass  which 
pressed  on  vena  cava.     Under  surface    of   diaphragm  studded  with 


480  FLUID    IN    THE    PEKITONETJM.  lect.  xii. 

small  masses  of  cancer,  and  the  small  nodules  felt  during  life  m  ab- 
dominal wall  were  of  a  similar  structure.  Much  rigidity  along  attached 
margin  of  aortic  valves,  which  were  competent. 

In  the  next  case  there  was  a  large  collection  of  fluid  in  the 
peritoneum  due  to  compression  of  the  portal  vein  by  a  colloid 
tumour.  The  fluid  di-awn  off  by  paracentesis  was  turbid  from 
the  presence  of  blood  and  cells  of  colloid  matter. 

Case  CLXIV. — Ascites — Colloid  Disease  of  the  Stomach  and  Peritoneum. 

Daniel  G ,  cabinet  maker,  aged  44,  adm.  into  Middlesex  Hosp. 

Dec.  1,  1868.  No  history  of  malignant  disease  in  family.  When  24 
he  had  primary  syphilis,  followed  ten  years  later  by  nodes  on  shins. 
Had  been  occasionally  intemperate,  but  not  a  habitual  tippler.  Eight 
months  before  admission  began  to  suffer  from  debility,  loss  of  appetite, 
and  constipation  ;  and  four  months  before,  became  jaundiced  and  con- 
tinued so  for  a  month.  After  this  continued  weak  and  low  until  nearly 
a  month  before  admission,  when  he  observed  some  swelling  of  belly, 
and  after  a  few  days  he  bad  an  attack  of  acute  pain  in  abdomen  which 
lasted  some  hours.  Swelling  rapidly  increased,  and  about  a  week 
before  admission  two  gallons  of  clear  straw-coloured  serum  were  drawn 
off  by  paracentesis.  This  gave  temporary  relief,  but  fluid  began  at 
once  to  reaccumulate.  Since  swelling  commenced  he  had  taken  much 
purgative  medicine  and  had  rapidly  lost  flesh. 

On  admission,  no  trace  of  jaundice  nor  of  oedema  of  integuments, 
but  abdomen  enormously  enlarged  in  comparison  with  very  emaciated 
body,  from  presence  of  fluid  in  peritoneal  cavity.  Girth  at  umbilicus 
35^  in.  Veins  of  abdominal  parietes  dilated.  No  pain  nor  tenderness 
on  pressure  over  abdomen.  No  appreciable  tumour,  but  splenic  dulness 
increased  and  hepatic  dulness  in  r.  m.  1.  rises  as  In'gh  as  Gth  rib,  al- 
though lower  edge  of  liver  cannot  be  felt  below  ribs.  Tongue  unusually 
red  and  fissured  in  centre;  gums  sore  and  slightly  swollen ;  frequent 
vomiting,  and  brings  up  food  nnd  medicine ;  bowels  very  relaxed — about 
12  motions  in  24  hours.  Pulse  96,  regular  and  feeble  ;  respirations 
thoracic;  organs  in  chest  noi-mal.  Temp.  98'4°.  Urine  contains  much 
lithates,  l)ut  no  albumen  nor  bile-pigment. 

Remedies  prescribed  were  ice  to  suck,  with  iron  and  digitalis, 
vegetable  charcoal  and  stimulants.  Diarrha^a  abated,  but  swelling 
rapidly  increased,  and  on  Dec.  4,  7^  pints  of  fluid  were  drawn  off  by 
paiHcentesis.  Fluid  was  turbid  nnd  reddish-brown;  sp.  gr.  1017;  it 
contained  no  flakes  of  lymph,  but  under  microscope  presented  numerous 
blood-corpuscles  and  several  large  cells  with  granular  contents,  exactly 
like  those  found  in  colloid  material  after  death.  After  fluid  was  drawn 
off,  still  no  tumour  could  be  felt,  and  liver  did  not  appear  enlarged. 
Operation  was  followed  by  gi-eat,  but  temporaiy,  relief.  Fluid  reaccumu- 


iKCT.  xii.  ILLUSTRATIVE    CASES.  48 1 

lated ;  vomiting  persisted ;  and  prostration  increased   until  death  bj 
exhaustion  on  Dec.  8. 

Autopsy. — Several  pints  of  bloody  serum  in  abdomen.  An  enormous 
deposit  of  colloid  material  in  great  omentum,  forming  a  large  mass 
covering  intestines.  Similar  deposits  on  inner  surface  of  abdominal 
parietes  apposed  to  mass  in  omentum,  on  under  surface  of  diaphragm 
and  over  liver.  A  large  mass  extending  along  lesser  omentum  into 
portal  fissure  surrounded  and  compressed  portal  vein,  but  interior  of 
vessel  free  from  coagulum.  Growth  nowhere  penetrated  into  sub- 
stance of  liver.  To  naked  eye,  morbid  material  appeared  to  consist  of 
an  aggregation  of  small  nodules  of  translucent  gelatinous  material,  and 
it  had  the  usual  microscopic  structure  of  colloid.  At  pyloric  end  of 
stomach  and  extending  for  5  in.  from  valve  was  an  extensive  colloid 
deposit  involving  all  the  coats ;  mucous  membrane  over  it  had  quite 
disappeared,  leaving  morbid  tissue  bare  and  exposed.  Spleen  invested 
by  colloid  deposit,  but  normal  and  weighed  only  b^  oz. 


I  I 


482 


LECTURE   XIIT. 

A.   PAIN  IN   THE  LIVER— B.    GALI^STONES—C.   ENLARGE- 
MENTS OF  GALL-BLADDER. 

A.  HEPATIC  PAIN  SIMULATED  BY:  1.  PLEURODYNIA — 2.  INTERCOSTAL  NEURALGIA — 3. 
PLEURISY — 4.  GASTRIC  DYSPEPSIA — 5.  INTESTINAL  COLIC — 6.  RENAL  COLIC.  THE 
"VARIETIES   AND    CAUSES    OF    GENUINE    HEPATIC    PAIN. 

B.  GALL-STONES.       THEIR    VARIOUS    CONSEQUENCES    AND    SYMPTOMS. 

C.  ENLARGEMENT    OF    GALL-BLADDER.        ITS    CAUSES,    CLINICAL    CHARACTERS,    AND    TREAT- 

MENT. 

A.    HEPATIC    PAIN. 

Gentlemen, — Pain  is  sometimes  the  most  prominent  symptom 
of  disease  of  the  liver  and  is  often  an  important  aid  to  diagno- 
sis. You  must,  however,  beware  of  being  misled  by  patients 
who  constantly  ascribe  pain  to  the  liver  with  which  that  organ 
is  in  no  way  concerned.  In  forming  a  diagnosis  3'Ou  must 
keep  constantly  in  view  the  various  conditions  which  may 
simulate  hepatic  pain.  The}'  are  mainly: — 1.  Pleurodynia,  2. 
Intercostal  Neuralgia,  3.  Pleurisy,  4.  Gastric  Dyspepsia,  5. 
Intestinal  Colic,  C.  Eenal  Colic. 

1.  Pleurodynia,  or  rheumatism  of  the  intercostal  muscles, 
may  be  situated  in  the  right  hypochondrium,  and  then  the 
acute  pain,  increased  by  pressure,  by  movement,  by  taking  a 
long  inspiration,  or  by  coughing,  and  accompanied  by  short 
jerking  respirations,  may  be  mistaken  for  the  pain  of  peri- 
hepatitis ;  but  it  differs  from  this — 

a.  In  the  pain  being  more  localised.  It  is  often  confined  to 
one  spot  between  two  ribs,  and  there  is  no  tenderness  on 
pressure  over  the  epigastrium,  or  elsewhere  in  the  hepatic 
region  than  in  the  spot  to  which  the  patient  refers  the  pain. 

h.  In  the  absence  of  symj)toms  of  pyrexia  or  of  constitu- 
tional disturbance. 

c.  In  the  absence  of  any  other  symptom  or  sign  of  hepatic 
disease. 


LECT.    XIII. 


PAIN   IN"   THE    LIVER.  483 


d.  Ill  the  occasional  coexistence  of  muscular  rheumatism  in 
other  parts  of  the  body. 

2.  Intercostal  Neuralgia,  except  that  the  pain  is  more  inter- 
mittent, may  present  many  of  the  characters  of  pleurodynia,  and 
may  like  it  be  localized  in  the  hepatic  region ;  but  on  the  whole 
it  is  chiefly  met  with  in  the  sixth  to  the  ninth  intercostal  spaces 
on  the  left  side,  and  in  females.  When  it  occurs  in  the  hepatic 
region,  it  differs  from  true  hepatic  pain — 

a.  In  the  pain  being  chiefly  referred  to  three  points  in  the 
course  of  the  nerve,  viz.  in  the  vertebral  groove,  in  the  axillary 
region,  and  at  the  termination  of  the  nerve  in  front. 

h.  In  the  frequent  coexistence  of  neuralgia  of  the  mammary 
gland,  tenderness  over  one  of  the  dorsal  spines,  or  cutaneous 
hj^persesthesia. 

c.  In  the  absence  of  any  other  symptom  or  sign  of  hepatic 
disease. 

You  must  not  forget,  however,  what  I  told  you  in  a  former 
lecture,  that  intercostal  neuralgia  may  have  a  hepatic  origin 
and  may  be  a  sequel  of  pain  which  is  truly  in  the  liver  (p.  338). 

3.  Fleurisy  may  give  rise  to  a  pain,  which,  like  that  of 
pleurodynia,  is  increased  by  pressure,  movement,  inspiration, 
or  coughing,  but  which  differs  in  being  associated  with  more 
or  less  pyrexia,  and  if  the  inflammation  be  at  the  base  of  the 
right  pleura,  the  pain  may  be  indistinguishable  from  that  of 
peri-hepatitis.  It  is  probable  indeed  that  in  some  of  the  cases 
of  so-called  diaphragmatic  pleurisy  the  inflammation  is  on  the 
under  surface  of  the  diaphragm  rather  than  on  the  ujjper,  while 
observations  in  the  dead  house  leave  little  doubt  that  in  many 
there  is  inflammation  on  both  sides.  Dulness  on  percussion  or 
pleuritic  friction  over  the  base  of  the  lung,  or  the  concun-ence 
of  pneumonia,  will  often  assist  the  diagnosis  in  favour  of 
pleurisy;  but  in  slight  cases  of  diaphragmatic  j)leurisy  there 
may  be  neither  dulness  nor  friction,  and  peri- hepatitis  will 
occasionally  give  rise  to  a  rubbing  sound  during  the  respiratory 
movements.     (See  Case  XYII.,  p.  90.) 

4.  Gastric  Dyspepsia. — Patients  very  commonly  refer  the 
pain  arising  from  various  disorders  of  the  stomach  to  disease 
of  the  liver.  The  liver  is  said  to  be  out  of  order,  when  the 
stomach  or  the  duodenum  is  the  organ  really  at  fault.  On  the 
other  hand,  we  have  found  that  attacks  of  pain  are  often  put 
down  to  gastralgia,  which  are  in  reality  slight  attacks  of  biliary 
colic  (p.  339). 

Ii2 


484  PAIN    IN    THE    LIVER 


LECT.    XIII. 


a.  Pain  coining  ou  after  food  may  be  due  to  derangement 
of  tlie  stomach  or  duodenum,  or  more  rarely  to  congestion  of 
the  liver;  but  the  liver  is  not  likely  to  be  the  source  of  the  pain, 
unless  there  be  tenderness  on  pressure  in  the  right  hypochon- 
drium  and  those  other  signs  of  congestion  of  the  liver  which 
I  have  already  described  to  you  (p.  182). 

h.  Attacks  of  severe  pain  (gastrodynia)  occur  in  the  stomach 
independently  of  food,  and  may  simulate  hepatic  colic  or 
hepatic  neuralgia.  From  hepatic  colic  it  will  be  distinguished 
by  its  situation,  by  its  being  often  accompanied  by  the  eructa- 
tion of  watery  fluid  (pyrosis),  and  by  the  absence  of  jaundice, 
or  of  bile-pigment  in  the  urine,  or  of  tenderness  on  pressure 
over  the  gall-bladder  (see  p.  339) .  Neuralgia  of  the  stomach  can 
only  differ  from  hepatic  neuralgia  in  the  situation  of  the  pain. 

0.  Intestinal  Colic  resembles  hepatic  colic  in  there  being  par- 
oxysms of  severe  abdominal  pain  with  vomiting  and  shivering, 
but  without  acute  tenderness  on  pressure.  It  differs  from  it  in — 

a.  The  situation  of  the  pain,  which  is  referred  to  the  um- 
bilicus rather  than  to  the  epigastrium  and  right  scapula. 

b.  The  absence  of  jaundice,  or  of  bile-pigment  in  the  urine. 

c.  The  absence  of  any  tenderness  on  pressure  over  the 
fundus  of  the  gall-bladder. 

d.  The  circumstances  under  which  it  occurs,  viz.  :  con- 
stipation ;  some  obvious  error  in  diet ;  the  presence  of  lead  in 
the  system,  indicated  by  the  blue  line  along  the  margin  of  the 
gums,  by  a  history  of  lead  colic  or  palsy,  or  by  the  patient's 
occupation.     Both  may  occur  in  persons  of  a  gouty  habit. 

6.  In  Renal  Colic  there  is  also  severe  paroxysmal  abdominal 
pain  with  vomiting  and  shivering,  but — 

a.  The  pain  is  referred  chiefly  to  one  kidney,  and  thence  it 
shoots  down  the  corresponding  thigh  and  down  to  the  corre- 
sponding testicle,  which  is  retracted. 

h.  Tliere  is  no  jaundice. 

c.  There  is  tenderness  over  the  kidney,  but  not  over  the 
fundus  of  the  gall-bladder. 

d.  The  urine  contains  blood  and  crystals,  which  may  require 
the  microscope  for  their  detection,  or  there  is  a  previous  history 
of  hajinaturia,  or  of  the  passage  of  a  calculus  by  the  urethra. 

Keeping  in  mind  these  sources  of  I'allacy,  we  may  proceed 
to  consider  the  varieties  and  causes  of  pain  which  is  justly 
referable  to  the  liver.  It  will  suffice  in  most  instances  if  I 
merely  uientiun  the  diseases  in  which  the  pain  occurs,  inasmuch 


LECT.  XIII.  ITS    VARIETIES    AND    CAUSES.  485 

as  I  have  already  described  their  leading  characters  to  you  in 
former  lectures.  I  may  remind  you,  however,  that  certain 
diseases  of  the  liver  are  characterised  by  a  remarkable  immimity 
from  pain,  and  more  especially  the  waxy  liver  (p.  33),  the 
fatty  liver  (p.  48),  simple  hypertrophy  (p.  54)  and  atrophy 
(p.  257),  and  hydatid  tumour  (p.  58). 

Pain  having  its  source  in  the  liver  may  be  said  to  present 
three  varieties. 

I.  First,  there  is  a  pain  which  is  very  severe,  comes  on  in 
paroxysms  with  distinct  intermissions,  and  is  associated  with 
little  or  no  tenderness,  except  in  the  region  of  the  gall-bladder, 
and  with  little  or  no  fever,  but  is  often  attended  or  followed  by 
jaundice.     Pain  answering  to  this  description  results  from : 

1.  The  presence  of  gall-stones  or  other  foreign  bodies  in  the 
bile-ducts  (see  pp.  337,  344,  and  345). 

2.  Obstruction  of  the  common  bile-duct  by  a  duodenal 
ulcer  (see  p.  349). 

3.  An  aneurism  of  the  hepatic  artery  (see  p.  356). 

4.  Hepatic  neuralgia.  This  has  been  described  by  Andral, 
Prerichs,'  Budd,^  Anstie,^  and  other  writers,  and  although  it  is 
probable  that  in  most  of  the  reported  examples,  and  especially 
in  those  where  there  has  been  jaundice,  the  pain  has  been  due 
to  gall-stones  which  have  not  been  passed  (see  p.  339),  or  which 
have  escaped  observation,  there  are  others  which,  occurring  in 
nervous  persons  or  hysterical  females,  often  at  tolerably  regular 
intervals  of  about  a  month,  associated  with  other  nervous 
symptoms  and  with  no  jaundice,  seem  really  to  be  instances  of 
neuralgia  of  the  hepatic  plexus  of  nerves.  I  must  add,  how- 
ever, that  I  do  not  remember  to  have  met  myself  with  an 
unmistakable  example  of  hepatic  neuralgia,  and  as  an  illustra- 
tion of  the  risk  of  fallacy  in  its  diagnosis  I  may  refer  to  a  case 
which  I  believed  to  be  of  this  nature,  and  on  which  I  gave 
a  clinical  lecture  some  years  ago.^  The  patient  was  liable  to 
severe  paroxysms  of  pain  in  the  right  hypochondrium  and  shoot- 
ing back  to  the  scapula,  coming  on  about  once  a  month  suddenly 
and  lasting  an  entire  day,  occasionally  accompanied  by  vomiting, 
but  never  followed  by  jaundice  or  any  tenderness  over  the  gall- 

*  Frerichs,  Dis.  of  Liver,  Syd.  Soc.  Ed.,  ii.  548. 

*  Eudd,  Dis.  of  Liver,  3rd  ed.  p.  380. 
=  On  Neuralgia,  London,  1871,  p.  62. 

*  The  case  was  recorded  as  one  of  '  Hepatic  Neuralgia '  in  the  first  edition  of  these 
Lectures,  Case  XC,  p.  497. 


486  PAIN    IN   THE    LIVER.  lkct.  xin. 

bladder.  These  paroxysras  continued  to  recnr  for  several  j^ears, 
until  at  length  their  real  nature  was  revealed  by  their  being 
accompanied  bj  hasmaturia  and  the  passage  of  oxalates  in  the 
urine.  Notwithstanding  the  unusual  situation  and  radiation 
of  the  pain,  the  paroxysms  were  probably  nephritic. 

II.  Secondly,  there  is  a  pain  in  the  liver  which  is  not  severe 
and  is  often  described  rather  as  a  feeling  of  weight  or  disten- 
sion, which  is  often  associated  with  pain  in  the  right  shoulder, 
which  does  not  intermit,  and  which  is  slightly  increased  by 
pressure,  or  by  lying  on  the  left  side,^  or  after  meals.  This 
pain  is  often  associated  with  slight  febrile  disturbance  and 
more  or  less  jaundice.  Pain  of  this  description  is  observed 
in : — 

1.  The  various  forms  of  congestion  of  the  liver  (p.  132). 

2.  The  early  stages  of  hepatitis  (pp.  139,  182). 

3.  Catarrh  of  the  bile-ducts  (p.  152). 

4.  Obstruction  of  the  common  duct  followed  by  great 
accumulation  of  bile  within  the  liver  (p.  161). 

5.  The  pain  in  acute  atrophy  (p.  261)  partakes  somewhat 
of  this  character. 

III.  A  third  form  of  pain  is  constant  and  severe,  is  greatly 
aggravated  by  pressure,  movement,  or  coughing,  and  is  asso- 
ciated with  more  or  less  fever,  but  not  often  with  jaun- 
dice. This  pain  may  be  attended  by  a  grating  sound  like 
pleuritic  friction  and  by  dry  cough,  but  the  case  is  distinguished 
by  the  marked  tenderness  over  the  liver  generally,  and  by  the 
pain  being  greatly  increased  when  the  patient  lies  on  the  left 
side  as  well  as  on  the  right.  This  is  the  pain  of  peri-hepatitis, 
which,  as  I  have  already  told  you,  although  sometimes  a  primaiy 
affection,  and  then  usually  syphilitic,  is  more  commonly 
secondary  to  other  diseases  of  the  liver.  Peri-hepatitis  accounts 
for  the  acute  pain  that  occurs  in  diseases  such  as  cirrhosis 
(p.  281),  waxy  enlargement  (p.  33),  or  hydatid  of  the  liver 
(p.  58) ,  whose  natural  course  is  painless ;  or  it  may  aggravate 
the  already  existing  pain  of  abscess  (pp.  165,  183),  or  cancer 
(p.  210).  Whatever  ma}^  be  the  primary  disease  of  the  liver, 
pain  of  the  character  last  described  always  indicates  inflamma- 
tion of  the  capsule,  and  its  supervention  sometimes  furnishes 
indications  of  some  imj)ortance.  Its  occurrence,  for  instance, 
in  a  case  of  hydatid  of  the  liver  would  indicate  that  the  hydatid 

'  Great  enlargement  of  the  liver  from  any  cause  will  also  give  rise  to  a  dragging 
pain,  when  the  patient  lies  on  the  left  side. 


LECT.  xiii.  GALL-STONES,    THEIR   CONSEQUENCES.  48/ 

was  about  to  burst  or  contract  adbesions  to  some  of  the  adjacent 
viscera. 

In  former  lectures  I  have  brought  under  your  notice  many 
examples  of  diseases  of  the  liver  in  which  pain  was  a  prominent 
symptom,  and  to  which  I  beg  again  to  call  your  attention. 

B.    PATHOLOGICAL    CONSEQUENCES    OP    GALL-STONES. 

In  what  remains  of  this  lecture  I  wish  to  say  a  few  words 
on  the  subject  of  gall-stones  and  diseases  of  the  gall-bladder. 
In  a  former  lecture,  when  spealdng  of  the  causes  of  jaundice,  I 
described  to  you  at  some  length  the  consequences  of  gall-stones 
passing  along  the  bile-ducts,  or  becoming  impacted  in  the 
common  duct,  but  in  doing  so  I  by  no  means  exhausted  their 
clinical  history.  I  purpose  now  supplying  this  deficiency  by 
calling  your  attention  to  the  different  situations  in  which  gall- 
stones are  found,  to  the  erratic  courses  which  they  sometimes 
take  in  their  endeavour,  so  to  speak,  to  escape  from  the  body, 
and  to  the  varying  symptoms  and  dangers  which  may  result 
from  them  accordingly.  Those  of  you  who  wish  to  have  further 
information  on  the  subject  of  gall-stones  I  would  refer  to  the 
elaborate  Memoir  of  M.  Fauconneau-Dufresne,  which  obtained 
the  prize  of  1,500  francs  from  the  French  Academy  of  Medicine 
in  1847.1 

1.  Gall-stones  'may  he  retained  in  the  Gall-bladder. — The  gall- 
bladder is  the  portion  of  the  biliary  passages  in  which  calculi 
are  found  most  frequently  and  in  largest  quantity,  and  there  is 
abundant  evidence  that  they  may  exist  there  for  a  long  time 
without  giving  rise  to  symptoms  of  any  sort.  You  will  con- 
stantly find  concretions  in  the  gall-bladder  after  death  in  the 
bodies  of  persons  who  during  life  have  exhibited  no  symptoms 
of  their  presence.  But  occasionally,  when  the  concretions  are 
numerous  and  large,  they  cause  a  sensation  of  uneasiness, 
weight,  tension,  or  dragging,  in  the  region  of  the  gall-bladder, 
which  is  usually  worse  after  meals,  after  any  violent  muscular 
exertion,  or  after  driving  over  rough  roads.  I  have  now  under 
my  care  a  lady  who  has  suffered  from  gall-stones,  and  who 
frequently  complains  of  a  sensation  of  a  heavy  weight  rolling 
from  side  to  side  in  the  situation  of  the  gall-bladder  when  she 
turns  in  bed.  Fauconneau-Dufresne  quotes  a  precisely  similar 
*  La  Bile  et  ses  Maladies,  M^m  de  I'Acad.  Eoy.  de  Med.  ]847,  xiii.  p.  36. 


488  GALL-STONES  : 


LBCT.  xin. 


case  from  Fabricius  Hildanus.'  Gall-stones  in  the  gall-bladder 
also  now  and  tlien  cause  vomiting  and  other  derangements  of 
the  stomach,  and  their  pressure  on  the  stomach  has  been  known 
to  determine  all  the  symptoms  of  stricture  of  the  pylorus.  It 
is  very  possible  also  that  in  persons  of  a  nervous  constitution 
they  may  be  a  centre  of  ii-ritation,  from  which  may  arise  uneasy 
sensations  and  symptoms  of  actual  disease  in  distant  parts  of 
the  body,  with  great  mental  depression  and  hypochondriasis. 
Several  cases  which  have  been  under  my  care  have  served  to 
impress  me  strongly  with  this  opinion. 

When  the  gall-bladder  is  full  of  concretions,  it  sometimes 
forms  a  tumour  which  is  appreciable  through  the  abdominal 
parietes,  and  the  real  nature  of  which  may  be  recognised  by  its 
hard  and  resisting  character.  On  palpation,  also,  a  peculiar 
crackling  sensation,  or  an  actual  sound,  is  in  rare  instances 
elicited,  which  has  been  aptly  compared  to  that  produced  by 
grasping  a  bag  of  hazel-nuts  or  by  rolling  about  small  pebbles 
in  the  mouth.  The  stethoscope  in  these  cases  may  afford 
material  assistance  in  the  diagnosis. 

Gall-stones  retaiiied  in  the  gall-bladder  may  also  excite 
inflammation  and  ulceration  of  the  mucous  membranej  and 
ulterior  consequences  to  be  presently  referred  to. 

2.  Gall-stones  may  become  impacted  in  the  necli,  or  in  the 
cystic  duct,  of  the  gall-bladder. — When  a  concretion  passes  from 
the  gall-bladder  into  the  cystic  duct,  it  usually  gives  rise  to 
vomiting  and  the  symptoms  of  biliary  colic  already  describe(. 
(p.  337),  but  so  long  as  it  does  not  advance  beyond  the  cysti 
duct  there  is  no  jaundice.  Sometimes  the  calculus  neve', 
reaches  the  common  duct ;  it  becomes  impacted  in  the  cystic 
duct,  or  it  drops  back  into  the  gall-bladder,  and  in  either  cas» 
the  colic  may  cease  without  there  having  been  any  jaundice. 
At  the  same  time  in  post-mortem  examinations  one  occasionallj 
finds  the  neck  of  the  gall-bladder  obstructed  by  an  impacted 
galV-stone,  although  no  symptom  leading  to  the  suspicion  ot 
gall-stones  has  ever  been  observed  during  life.  Permanent 
obstruction  of  the  cystic  duct  by  a  calculus  may  lead  to  inflam- 
matory enlargement  of  the  gall-bladder,  to  the  consideration 
of  which  we  shall  presently  return. 

3.  Gall-stones  may  form  in  the  radicles  of  the  hepatic  duct  in 
the  interior  of  the  liver. — It  is  not  often  that  concretions  form  in 
the  bile-passages  within  the  liver,  inasmuch  as  the  bile  is  not 

'  rauconneau  Dufretine,  op.  cit.  p.  274. 


LECT.  XIII.  THEIR   CONSEQUENCES    AND    SYMPTOMS.  489 

here  subjected  to  those  conditions  of  concentration  and  repose, 
which  contribute  so  much  to  their  formation  in  the  gall-bladder. 
They  have  sometimes  been  found,  however,  in  the  dilated  bile- 
ducts  within  the  liver  in  cases  of  obstruction  of  the  ductus 
communis  choledochus,  and  there  are  also  a  few  cases  on  record 
where  biliary  concretions  have  been  found  within  the  liver 
independently  of  any  such  obstruction.  These  concretions 
may  be  numerous,  but  very  small,  constituting  what  has  been 
called  '  biliary  gravel ; '  at  other  times  they  are  large  and 
branched  like  a  piece  of  coral,  as  in  this  drawing  which  is 
copied  from  one  of  Cruveilhier's  Pathological  Plates.^  Chopart 
met  with  a  case  where  the  liver  contained  so  many  concretions 
that  it  could  not  be  cut  with  a  scalpel.^  These  concretions  in 
the  liver  may  induce  partial  obstructions  of  bile  and  dilatation 
of  the  ducts  ;  sometimes  they  become  enclosed  in  firm  fibrous 
cysts,  shut  off  from  the  bile-ducts;  and  at  other  times  they 
cause  cystic  dilatation  and  ulceration  of  the  ducts  and  multiple 
abscesses  in  the  liver.  A  case  has  been  recorded  by  Dr.  Tuck- 
well  where  a  large  abscess  in  the  right  lobe  of  the  liver  formed 
in  this  way  perforated  the  diaphragm  and  caused  empyema  and 
gangrene  of  the  right  lung.^ 

The  symptoms  of  intra-hepatic  concretions  are  usually 
obscure.  They  do  not  cause  jaundice  nor  enlargement  of  the 
liver,  and  the  smaller  concretions  may  cause  no  pain.  But  now 
and  then  they  give  rise  to  a  feeling  of  weight,  or  of  dull  pain, 
in  the  region  of  the  liver,  with  sudden  a.ttacks  of  sharp  cutting 
pain  or  violent  colic  shooting  from  the  right  hypochondrium. 
through  the  chest  or  to  the  hypogastrium,  while  in  other  cases 
they  have  occasioned  attacks  of  rigors  *  followed  by  heat  and 
sweating,  which  have  simulated  ague.  Fauconneau-Dufresne 
records  at  length  a  case  which  was  diagnosed  by  Professor 
Trousseau,  from  his  finding  biliary  concretions  in  the  motions 
associated  with  attacks  of  pain  like  that  which  I  have  described.^ 

4.  Gall-stones  may  he  impacted  in  the  hepatic  duct,  before  its 
junction  with  the  cystic  duct,  but  this  is  a  rare  occurrence.  A 
concretion  in  this  situation  must  be  derived  from  the  ducts 
within  the  liver,  and  if  a  calculus  has  succeeded  in  escaping 
from  the  small  ducts  in  the  liver,  it  is  not  likely  to  encounter 
any  serious  obstacle  to  its  progress  or  to  cause  symptoms  of 

1  Livraison  xii.  PI.  V.  -  Fauconneau-Dufresne,  op.  cit.  p.  249. 

s  Path.  Trans.  1870,  vol.  xxi.  p.  223. 

*  Frerichs,  op.  cit.  ii.  516.  ^  Op.  cit.  p.  270. 


490  GALL-STONES  :  i-ect.  xiii. 

any  importance  in  its  passage  tlirough  tlie  larger  liepatic  duct. 
It  is  not  surprising  then  that  there  are  very  few  cases  on  record 
where  a  large  gall-stone  has  been  found  obstructing  the  hepatic 
duct  after  death ;  but  where  this  does  happen  during  life,  there 
would  be  jaundice,  enlargement  of  the  liver,  vomiting,  biliary 
colic,  and  those  other  symptoms  of  obstruction  of  the  common 
duct  which  ha,ve  been  already  detailed  to  you  (p.  387).  There 
would,  however,  be  no  enlargement  of  the  gall-bladder,  as  when 
the  common  duct  is  obstructed. 

5.   Gall-stones  may  he  lodged  in  the  ductus  communis  choledo- 
chus. — This,  in  fact,  is  one  of  their  most  common  situations, 
and  they  find  their  way  here  from  one  of  two  sources,  either 
from  the  intra-hepatic   ducts,   or   more   conmionly   from   the 
gall-bladder.     As  a  rule  they  are  discharged  sooner  or  later 
into  the  duodenum,  their  passage  being  marked  by  those  sym- 
ptoms of   biliary  colic  which  I  have  already  endeavoured  to 
describe  to  you.     The  passage  of  the  concretion  through  the 
cystic  duct  gives  rise  to  severe  colic,  but  when  it  enters  the 
common  duct  jaundice  is  added  to  the  former  symptoms,  and, 
in  consequence  of  the  larger  size  of  the  common  duct,  the  pain 
usually  abates  in  severity,  again  to  return  with  even  increased 
intensity  on  the  arrival  of  the  concretion  at  the  narrow  duo- 
denal orifice,  on  dropping  through  which  it  sometimes  ceases 
suddenly,  as  if  by  enchantment.     More  rarely  the  calculus  is 
firmly  impacted  in  the  common  duct  and  becomes  one  of  the 
causes  of  permanent  jaundice.     A  rough  angular   stone   will 
experience  more  difficulty  and  cause  more  pain  in  passing  along 
the   duct,  than   one  which  may  be  larger  but  is  rounded  and 
smooth,  but  at  the  same  time  it  is  more  likely  to  permit  a  little 
bile  to  trickle  past  it.     Now  and  then  the  common  bile-duct  is 
found  dilated  into  a  large  pouch  containing  numerous  calculi, 
but  at  the  san)e  time  allowing  the  bile  to  pass  on  to  the  bowel. 
I  recently  met  with  this  condition  in  the  body  of  a  lady  whose 
case  I  shall  take  another  opportunity  of  relating  to  you  (Case 
CLXV),  and  a  similar  appearance  is  figured  in  one  of  Cruveil- 
hier's  Plates.^      Morgagni  long  ago  reported  a  case  where  the 
common  bile-duct  was  dilated  to  the  size  of  a  small  bottle  and  was 
full  of  calculi,^  and  more  recently  a  case  has  been  recorded  by 

'  An.it.  Path.  Livraison  xxix.  PI,  IV.  fig.  3. 

^  Trous.«eau,  Clin.  Med.  ii.  532.  The  common  bile-duct  in  this  case  is  commonly 
quoted  as  having  been  dilated  to  the  size  of  the  human  stomach,  owing,  as  Dr. 
Wiekham  Legg  has  pointed  out.  to  Morgagni,  in  quoting  the  case  from  8cheuk, 
having  converted  the  words  '  inslar  utriculi'  iuto  'instai'  veut.riculi.' 


LECT.  xiii.  THEIR    CONSEQUENCES    AND    SYMPTOMS.  49I 

Frerichs  in  which  it  was  converted  into  a  sac  measuring  8  in. 
in  length  and  5  in  width.  ^ 

6.  Gall-stones  may  excite  wfiammation  and  ulceration  of  the 
lining  membrane  of  the  gall-bladder  or  hile-ducts,  and  may  thus 
lead'  to  -perforation  and  peritonitis  or  pycemia. — While  b'till  in 
the  gall-bladder  or  in  any  i^art  of  the  biliary  passages,  gall- 
stones may  be  followed  by  other  consequences  besides  those 
already  mentioned.  Their  pressure  or  irritation  may  excite 
inflammation  of  the  mucous  membrane  with  which  they  are  in 
contact,  and  this  may  spread  through  the  entire  biliary  passages. 
You  will  remember  that,  when  lecturing  on  inflammation  of 
the  biliary  passages,  I  referred  to  the  irritation  of  gall-stones 
as  one  of  its  causes  (p.  154),  and  that  not  long  ago  we  had  an 
instance  of  inflammation  from  this  cause  in  the  wards  (Case 
LXVI.  p.  162).  Occasionally,  and  more  especially  when  the 
cystic  duct  is  obstructed,  inflammatory  products  accumulate  in 
large  quantity  in  the  gall-bladder  from  which  all  the  colouring 
matter  of  the  bile  is  absorbed,  and  the  gall -bladder  becomes 
converted  into  a  large,  painful,  fluctuating  tumour,  simulating 
an  abscess,  which  may  burst  in  different  directions,  or  may  be 
opened  by  the  surgeon,  as  in  Case  CLXX.  The  pressure  of 
gall-stones  may  also  cause  ulceration,  which  may  not  be  limited 
to  the  mucous  membrane,  but  may  perforate  the  entire  coats  of 
the  gall-bladder  or  of  a  bile-duct,  and  induce  fatal  peritonitis 
from  the  escape  of  bile  or  of  the  concretions  themselves  into 
the  peritoneum.  I  show  you  here  some  gall-stones  removed 
from  the  body  of  a  lady  lately  under  my  care,  who  died  suddenly 
of  peritonitis  from  ulceration  and  perforation  of  the  gall-bladder 
(see  Case  CLXIV.).  A  similar  case  has  been  reported  by  Dr. 
J.  W.  Ogle,^  and  you  will  find  in  Fauconneau-Dufresne's  memoir 
an  observation  quoted  from  Dr.  Wolf,  where  death  from  perito- 
nitis was  due  to  complete  rupture  of  the  hepatic  duct.^  Trous- 
seau also  mentions  a  case  where  a  calculus  and  a  considerable 
quantity  of  bile  escaped  into  the  peritoneum  through  a  rupture 
in  the  ductus  communis  choledochus.'*  In  some  of  these  cases 
the  rupture  seems  to  have  been  independent  of  ulceration,  and 
to  have  been  the  result  merely  of  undue  pressure  upon  the  coats 
of  the  biliary  passages,  which  have  perhaps  been  weakened  by 
inflammation  or  fatty  degeneration.'^     Fatal  peritonitis  in  these 

'  Op.  cit.  ii.  469.  *  St.  Geo.  Eosp.  Eep.  iii.  189. 

^  Op.  cit.  p.  273.  ■•  Clin.  MeJ.  ii.  533. 

*  See  Budd,  op.  oit.  p.  234. 


492  GALL-STONES  :  lect.  xiii. 

cases  is  sometimes  prevented  by  the  formation  of  adhesions  and 
the  establishment  of  biliary  fistulse,  or  the  calculus  may  escape 
from  the  gall-bladder  and  become  encysted  in  its  vicinity  by  orga- 
nised lvmj)h.^  Cases  have  also  been  recorded  where  gall-stones 
have  escaped  by  ulceration  from  the  biliary  passages  into  the 
substance  of  the  liver,  and  been  there  found  in  the  interior  of 
abscesses  which  communicated  with  the  biliary  passages.^  More 
commonly  it  happens  that  the  ulceration  or  sloughing  produced 
by  the  pressure  or  irritation  of  the  gall-stones  contaminates  the 
portal  blood,  and  leads  to  the  development  of  multiple  pysemic 
abscesses  in  the  manner  already  explained  to  you.  I  would  re- 
call to  your  recollection,  by  way  of  illustration,  the  instructive 

case  of  Mrs. (Case  LXXT.,  p.  173),  which  was  related  to 

you  in  a  former  lecture.  You  will  thus  see  that  an  attack, 
which  in  the  first  instance  may  appear  to  be  nothmg  more 
than  one  of  colic  from  gall-stones,  may  suddenly  and  unex- 
pectedly assume  all  the  symptoms  of  peritonitis  or  pyaemia,  and 
prove  fatal  ;  and  the  practitioner,  if  he  be  not  on  his  guard  in 
giving  a  prognosis,  may  incur  unmerited  discredit. 

7.  A  gall-stone  which  has  reached  the  hotvel  Tnay  he  voided  fer 
anum. — Once  arrived  in  the  bowel,  the  natural  exit  of  a  gall- 
stone from  the  body  is  by  the  anus,  and  this  is  the  termination 
which  it  is  the  great  object  of  treatment  to  promote.  As  a 
rule  all  symptoms  cease  as  soon  as  the  concretion  leaves  the 
bile-duct,  but  occasionally,  when  the  concretions  are  large,  or 
when  numerous  concretions  become  cemented  together  by 
fifical  matter  into  one  large  mass,  their  discharge  per  anum  is 
preceded  by  severe  colic,  vomiting,  and  great  prostration. 
Biliary  calculi  voided  per  anum  are  sometimes  remarkable  for 
their  size.  Fauconneau-Dufresne  ^  and  Frerichs  *  have  collected 
the  notes  of  several  cases  where  they  were  as  large  as  a  pigeon's 
or  even  a  hen's  egg,  and  in  the  Museum  of  the  Royal  College 
of  Sin-geons  are  two  calculi  jiassed  per  anum,  one  of  which 
measures  1 J  in.  by  1^  in.,  and  the  other  is  nearly  2  in.  in  length.* 
In  1808  Dr.  Hilton  Fagge  exhibited  to  the  Pathological  Society 
two  specimens  of  oval  biliary  concretions   passed   per   anum 

'  For  example,  see  Simon,  Pnth.  Trans,  v.  157;  and  Sharman,  Mod.  Timos  and 
Gazette,  1859,  i.  274. 

-  Fauconne.iu-Dufrcsne,  op.  cit.  p.  340  ;  and  Tuckwoll,  Path.  Trans.  1870,  xxi. 
223. 

'  Fauconnoan-Dnfrpsne.  op.  cit.  p.  319. 

*  Frerichs,  op.  cit.  ii.  523.  *  Catalogue  of  Calculi,  pp.  168,  176. 


LECT.  XIII.  THEIR    COKSEQUENCES    AND    SYMPTOMS.  493 

whose  long-  and  short  diameters  measured  about  2^  in.  by  I3- 
in.'  In  the  same  year  one  of  the  largest  gall-stones  on  record 
was  figured  in  the  Lancet  by  Mr.  J.  Blackburn.  It  was  3| 
in.  long,  and  1^  in.  wide,  and  weighed  1  oz.  6  dr.,  and  was 
said  to  have  been  passed  per  anum,  '  without  any  aggravation 
of  the  usual  signs  of  gall-stones.'  ^  In  most  instances  of  these 
large  concretions  it  is  probable  that  they  have  found  their  way 
into  the  bowel,  not  through  the  bile-duct,  but  through  a  biliary 
fistula  from  the  gall-bladder,  although  Eokitansky  observes 
that  owing  to  the  extreme  distension  which  the  biliary  passages 
are  capable  of,  calculi  of  the  size  of  a  hen's  egg  are  enabled  to 
pass  through  them.^ 

8.  Gall-stones  may  he  vomited  from  the  stomach. — In  rare 
instances  gall-stones  are  expelled  from  the  body  by  vomiting. 
Two  instances  are  reported  by  J.  L.  Petit,  in  one  of  which  the 
calculus  was  2i  in.  long.'*  Eight  others  have  been  collected  by 
Tauconneau-Dufresne ;  ^  one  is  reported  in  the  Pathological 
Transactions  by  Mr.  JeafFreson  of  Framlingham,  where  the 
concretion  was  larger  than  a  nutmeg  ;^  and  one  by  Dr.  E.  J. 
Miles,  where  sarcinous  vomiting  ceased  on  the  ejection  from 
the  stomach  of  two  large  gall-stones.'^  The  expulsion  of  the 
stones  has  usually  been  preceded  for  several  days  by  severe  pain 
in  the  stomach,  and  accompanied  by  violent  and  protracted 
vomiting.  It  has  been  the  custom  to  account  for  these  cases 
on  the  supposition  of  an  antiperistaltic  action  of  the  duode- 
num, but  in  most  of  the  recorded  instances  it  is  probable  that 
the  calculi  have  found  their  way  into  the  stomach  by  a  direct 
fistular  communication  with  the  gall-bladder.  This  view  is 
favoured  by  no  mention  being  made  of  jaundice  in  many  of  the 
cases;  by  several  calculi  being  vomited  in  some, — in  one  as 
many  as  twenty ;  and  by  one  patient  vomiting  a  calculus  on 
three   different  occasions  at  intervals  of  several  years. ^     The 

>  Path.  Trans,  xix.  254. 

^  Laucet,  1868,  ii.  784.     For  mention  of  a  larger  stone,  see  p.  496. 
"  Path.  Anat.,  Syd.  See.  Transl.  ii.  165. 

*  M6m.  de  I'Acad.  Roy.  de  Chir.  1743,  vol.  i.  p.  308. 
s  Op.  cit.  p.  306. 

•  Vol.  xii.  p.  129. 

'  Lancet,  Jan.  19,  1861. 

8  Since  this  lecture  was  delivered,  the  sequel  of  Mr.  .Teaffreson's  case  has  been 
ptiblished  by  his  brother.  Dr.  H.  JeaiFreson,  from  which  it  would  appear  that  the 
patient  died  shortly  after  the  report  of  her  case  to  the  Pathological  Society,  and  that 
the  gall-stone  was  found  to  have  escaped  by  ulceration  into  the  stomach.  Brit.  Med. 
Journ.  May  30,  1868.  j 


494  GALL-STONES  : 


LECT.    XIII. 


possibility,    indeed,    of    a    large   calculus   passing   backwards 
through  the  pylorus  is  very  doubtful. 

9.  Gall-stones  after  entering  the  hoivel  may  he  impacted  and 
become  a  cause  of  intestinal  ohstruction. — I  show  you  here  a 
specimen,  consisting  of  a  jDortion  of  the  ileum  with  a  large 
gall-stone  tightly  fitted  into  its  interior  like  a  cork,  which  was 
obtained  from  the  body  of  a  patient  who  died  in  this  (Middle- 
sex) hospital  a  few  years  ago  with  all  the  symptoms  of  intestinal 
obstruction  (Case  CLXVI.),  and  medical  literature  contains  the 
records  of  many  similar  cases.'  The  intestine  in  these  cases 
is  greatly  distended  above  the  obstruction,  but  contracted  and 
empty  below.  The  impaction  of  the  calculus  in  the  small  in- 
testine is  marked  by  obstinate  constipation,  vomiting,  first  of 
food,  then  of  bile,  and  lastly  of  stercoraceous  matter,  pain  and 
tenderness  of  the  abdomen  and  other  symptoms  of  peritonitis, 
which  symptoms  continue  until  death,  or  until  the  concretion 
escapes  into  the  large  bowel.  Although  these  cases  are  often 
fatal,  it  is  satisfactory  to  knovr  that  in  several  of  the  25  cases 
of  which  T  have  collected  the  notes,  the  concretion  has  been 
discharged  per  anum  and  the  patient  has  recovered,  even  after 
stercoraceous  vomiting  had  set  in.  In  one  of  the  cases  (Dr. 
Omond's)  stercoraceous  vomiting  had  lasted  upwards  of  three 
weeks,  and  yet  the  patient  recovered. 

A  concretion  which  has  foimd  its  way  through  the  bile-duct 
is  not  likely  to  become  arrested  in  the  bowel.  Accordingly,  in 
most  cases  of  obstruction  of  the  bowel  by  a  biliary  calculus 
this  has  passed  directly  from  the  gall-bladder  into  the  bowel  by 
a  fistulous  opening,  and  thus  there  may  be  no  previous  history 
of  jaundice  to  assist  in  diagnosing  the  cause  of  the  obstruction. 
For  example,  this  was  what  had  occurred  in  the  case  of  which 
I  have  shown  you  the  specimen.     On  the  other  hand,  you  will 

'  Five  cases  collected  by  Fauconnoau-Dufrcsnc,  op.  cit.  p.  311  ;  two  oliscrved  liy 
Cniveilliier,  Traite  d'Anat.  Path.  ii.  64  J ;  two  by  Frerichs,  op.  cit.  ii.  524;  one  by 
OppolzLT,  Zcitsc'b.  d  Gesellscliaft  d.  Aertze  in  Wien,  Nov.  ISGO;  one  by  Sir  Tho.s. 
Watson.  Lect.  Pract.  Phys.  3rd  ed.  ii.  465,  which  is  the  same  as  Mayo's  case  included 
in  l-auconncau-Dufresne's  five  ;  one  by  Dr.  Omond,  Loud,  and  ]Mcd.  Surg.  Journ.  1836  ; 
one  by  Peacock,  Trans.  Path.  Soc.  i.  255  ;  one  by  Pye  Sniitii,  ib.  v.  163  ;  one  by  Baly 
lb.  X.  185;  ono  by  Potts,  ib.  xv.  105;  one  by  Murcliison,  ib.  xx.  219;  one  by  J)r. 
Kzra  Palmer,  Records  Med.  Soc.  Bost.  U.S.  vol.  iii.  106;  one  by  Dr.  P.  Cani))liell, 
Med.  Times  and  Gay,.  1870,  i.  335  ;  one  by  Mr.  LeGros  Clark,  Med.  Chir.  Trans.  1 872, 
Iv.  1;  one  by  Dr.  J.  S.  Gray,  Clin.  Trans.  1873,  vi.  193;  one  by  Dr  Crichton 
Browne,  Brit.  Med.  Journ.  1875,  i.  345  ;  one  in  Coll.  Surg.  M us.  Path.  Ser.  No.  1182; 
one  in  Jiarth.  TIosp.  Mus.  Ser.  xvi.  No.  84.  See  also  Cases  CLXVI.  and  CLXVIL  and 
the  references  to  Cystico-duodtual  fistulse,  p.  497. 


LECT.  xiii.  THEIR   CONSEQUENCES    AND    SYMPTOMS.  495 

remember  Eokitansky's  statement  tliat  a  calculus  as  large  as  a 
lien's  egg  may  pass  throng-li  the  bile- ducts.  Abercrombie  also 
relates  the  case  of  a  man  who  after  many  attacks  of  colic 
followed  by  jaundice,  died  on  the  fifth  day  of  a  similar  attack, 
with  the  addition  of  symptoms  of  ileus.  A  biliary  calculus, 
measuring  4  by  3|  in.  in  circumference,  was  found  plugging 
the  ileum ;  the  gall-bladder  is  spoken  of  as  inflamed  and  par- 
tially disorganised,  but  no  mention  is  made  of  a  fistula,  while 
the  common  duct  was  patent  and  easily  admitted  the  finger.^ 
In  another  case,  reported  in  the  Pathological  Transactions  (xv. 
106),  where  the  concretion  in  the  ileum  had  a  circumference  of 
four  inches,  there  had  been  no  jaundice,  and  yet  there  were  no 
adhesions  about  the  gall-bladder,  which,  however,  was  not 
carefully  examined.  In  Mr.  Le  Gros  Clark's  case,  the  ileum 
was  obstructed  by  two  large  gall-stones  1  in.  in  length  and 
4  in.  in  circumference,  and  although  there  had  been  no 
jaundice  it  is  stated  that  there  was  nothing  to  indicate  that  tbe 
concretion  had  ulcerated  through,  into  the  duodenum  from  the 
gall-bladder.  It  is  difficult  to  account  for  these  cases,  if  they 
have  been  correctly  observed.  We  know,  however,  that  biliary 
concretions  may  acquire  increased  dimensions  in  the  bowel  from 
the  deposit  of  faecal  matter,  and  that  sometimes  they  form  the 
nucleus  of  large  intestinal  concretions  ;^  and  also  that  enor- 
mous biliary  calculi  may  be  lodged  for  a  long  time  in  pouches 
of  the  duodenum  or  jejunum,  without  causing  obstruction  of  the 
bowels,  which,  however,  might  ultimately  ensue.^ 

Ileus  from  gallrstones  is  distinguished  from  other  forms  of 
intestinal  obstruction  by  its  usually  occurring  in  females  of 
advanced  age,  by  a  previous  history  of  hypochondriac  in- 
flammation, by  the  intensity  of  the  pain,  the  incessant  and 
severe  vomiting,  the  frequent  and  intermittent  attacks  which, 
sometimes  seem  to  indicate  the  obstruction  of  the  stone  here 
and  there  in  its  passage  down  the  intestine,  and  the  rapidity 
with  which  the  last  attack  often  ends  in  death. ^ 

Several  cases  have  been  recorded  where  the  rectum  has 
been  obstructed,  just  above  the  sphincter  ani,  by  a  large  biliary 
concretion,  or  by  several  concretions  cemented  together  by 
faecal  matter.     Obstinate    constipation  and   considerable  pain 

'  Diseases  of  Stomach,  3rd  ed.  p.  127. 

2  See  Dr.  P.  H.  Watson,  Ed.  Med.  Journ.  May  1868,  p.  989. 

»  See  DuMn,  Lancet,  May  27,  1848,  and  G.  Harley,  Path.  Trans,  yiii.  235. 

■•  Brinton  on  Intestinal  Obst.  1867,  p.  75. 


496  GALL-STONES : 


LECT.    XIII. 


have  been  the  result,  but  under  suitable  treatment  the  con- 
cretion has  generally  been  voided  per  anum  and  the  patient 
has  recovered. 

10.  Gall-stones  may  excite  ulceraMon  or  gangrene  of  the  bowel, 
and  may  even  escajpe  from  it  by  a  perforation  into  the  peritoneum 
or  externally. — Tn  obstruction  of  the  small  intestine  by  biliary 
concretions,  death  usually  occurs  before  there  is  time  for  per- 
foration. Perforation  is  most  apt  to  happen  when  the  concre- 
tion is  situated  in  a  portion  of  the  bowel  where  it  can  remain 
for  a  long  time  without  causing  obstruction.  Thus  several  in- 
stances have  been  noted  where  biliary  concretions  in  the  csecum 
have  caused  ulceration,  gangrene,  perforation,  and  fatal  peri- 
tonitis. In  rare  cases  gall-stones  have  been  known  to  enter 
the  appendix  vermiformis,  and  like  other  foreign  bodies,  or  con- 
cretions formed  in  the  part,  to  cause  ulceration,  perforation,  and 
fatal  peritonitis.  In  most  of  the  cases  where  biliary  concre- 
tions either  in  the  csecum  or  in  the  appendix  have  been 
recorded  as  producing  perforation,  it  may  be  doubted  if  the 
concretions  were  not  intestinal  rather  than  biliary.'  Budd, 
however,  observed  a  case  where  a  gall-stone  in  the  vermiform 
appendix  caused  perforation  and  fatal  peritonitis,^  and  another 
patient  died  from  the  same  cause  under  the  care  of  Trousseau.' 
The  specimen  of  a  similar  case  is  preserved  in  the  Museum  of 
St.  Bartholomew's  Ho-^pital ;  *  and  some  years  ago  a  case  was 
related  by  Dr.  Adolphe  Sirey  where  a  circumscribed  abscess 
formed  round  the  appendix,  and  where  the  concretion  ulti- 
mately found  its  way  out  by  an  ulcerated  opening  through  the 
abdominal  wall.^  Lastly,  Dr.  Horace  Jeaft'reson  has  recorded  a 
case  where  two  large  gall-stones  became  shelved  in  a  slightly 
pouched  portion  of  the  ileum  just  above  the  valve,  and 
eventually  set  up  irritation  and  ulceration,  which  resulted  in 
pertoration  and  fatal  peritonitis,  and  where  one  of  the  gall- 
stones was  found  to  have  escaped  into  the  peritoneum.^ 

11.  Gall-stones  may  lead  to  fistulous  communications  between 
the  biliar\j  passages  and  adjacent  parts  within  the  abdomen. — 
Adhesions  form   between  the  gall-bladder  and  some  adjacent 

'  This  remark,  I  suspeot,  applies  to  most,  if  not  all,  of  the  cases  collected  by 
Fauconnoau-Dufresne.     Op.  cit,.  pp.  313,  31G. 
2  Dis,  of  Liver,  3rd  ed.  p.  378. 

'  Clin.  Jled.  ii.  />36.  *  Ser  xvi.  No.  65. 

»  Mod.  Times  and  fijiz.  18.19,  ii.  372. 
•  Brit.  Med.  Journ.  May  30,  1868,  p.  531. 


LECT.  xrn.  THEIR    CONSEQUENCES    AND    SYMPTOMS.  49/ 

viscus,  and  a  communication  is  tlien  established  by  ulceration 
advancing  from  the  gall-bladder,  or  by  gangrene. 

a.  Fistulce  into  the  Stomach  resulting  from  gall-stones  have 
been  already  referred  to.  Cruveilhier  observed  a  case  where  a 
fistula  between  the  gall-bladder  and  the  stomach  was  found 
closed  by  a  gall-stone.^  Oppolzer  met  with  a  case  where  the 
opening  was  found  close  to  the  pylorus,^  and  two  others  are 
referred  to  by  Frerichs.^  You  have  lately  seen  a  case  in  which 
there  was  a  fistulous  opening  between  a  dilated  bile-duct  in 
the  liver  and  the  stomach  (Case  CXIX.,  p.  372).  I  have  also 
told  you,  that  it  is  probably  in  consequence  of  this  lesion  that 
gall-stones  are  occasionally  expelled  by  vomiting.  Cruveilhier, 
indeed,  is  of  opinion,  that  the  very  circumstance  of  a  gall-stone 
being  vomited  is  a  positive  proof  of  the  existence  of  such  a 
fistulous  communication. 

h.  Fistulce  into  the  Duodenum  axe  not  very  uncommon  and 
are  almost  invariably  due  to  ulceration  or  gangrene  of  the 
biliary  passages  excited  by  gall-stones.  The  specimen  which  I 
hold  in  my  hand  is  a  good  example  of  this  fistula  and  was 
obtained  from  the  case  I  have  already  referred  to,  where  death 
was  due  to  ileus  from  the  impaction  of  a  large  stone  in  the  small 
intestine  (Case  CLXVI.).  I  have  collected  from  different  sources 
the  notes  of  34  cases  in  which  a  similar  fistula  existed,'* 
and  in  the  majority  of  them  the  cause  of  death  was  the  obstruc- 
tion of  the  small  intestine  by  a  large  biliary  calculus  which 
had  escaped  by  the  abnormal  passage  from  the  gall-bladder. 
In  several,  however,  a  large  calculus  was  passed  per  anum 
after   symptoms  of  obstruction  (Case  CLXVII.),   and,  if  the 

'  Traite  d'Anat.  Path.  ii.  541, 

''  Zeits.  der  GestUsch.  d.  Aerzte  in  Wien,  Nov.  1860. 

»  Op.  cit.  ii.  525. 

*  Eight  cases  collected  by  Faiiconneau-Dufresne,  op.  cit.  p.  336 ;  two  observed  by 
Cruveilhier,  Traite  d'Anat.  Path.  ii.  543  ;  two  by  Oppolzer,  Zeitschr.  der  Geseilsch. 
der  Aerzte  in  Wien,  Nov.  1860,  p.  767 ;  two  by  Frerichs,  op.  cit.  vol.  ii.  Obs.  74  and 
75 ;  one  by  Duffin,  Lancet,  May  27,  1 848  ;  one  by  Blagden,  referred  to  hy  Duffin,  but 
reference  given  is  wrong ;  one  by  Peacock,  Trans.  P;ith.  Soe.  i.  255  ;  one  by  J.  W. 
Ogle,  ib.  V.  161  ;  one  by  Pye  Smith,  ib.  v  163  ;  one  by  Baly  ?  ib.  x.  185  ;  one  by  Dr. 
Ezra  Palmer,  Records  Med.  Soc.  Boston,  U.S.  vol.  iii.  p.  106:  one  by  Dr.  Crichton 
Brown,  Brit.  Med.  Journ.  1875,  i.  345  ;  one  by  Trousseau,  Clin.  Lect.,  Syd.  Soc.  Ed.,  iv, 
251  ;  three  by  Dr.  J.  W.  Ogle,  St.  George's  Hosp.  Rep.  vol.  iii.  ;  my  own  Case  CLXVI. ; 
one  in  Mus.  Col.  &'urg.  Path.  Ser.  No.  1460  ;  two?  in  Barth.  Hosp.  Mus.  Ser.  xvi.  No. 
84  and  ser.  xix.  No.  11 ;  one  in  St.  Thos.  Hosp.  Mus.  No.  1412,  and  referred  to  in 
Soulh's  edition  of  Clielius'  Surgery,  i.  716;  one  in  Mus.  King's  College,  Lond.  Dig. 
Sj'st.  Nos.  57,  259,  and  272  ;  one  in  Charing  Cross  Hospital  Mus.  G.  3  ;  one  in  Mus. 
of  Med.  Soc.  of  Boston,  U.S.  No,  565,  New  Eng.  Journ.  of  Med.  and  Surg.  1825. 

K  K 


498  GALL-STONES 


LECT.    XIII. 


patient  surviv3  long  the  formation  of  the  fistula,  it  is  possible 
that  this  may  be  overlooked  after  death,  and  that  thus  the  lesion 
may  be  more  common  than  is  usually  supposed  (see  Case 
CLXVIII.).  The  opening  in  the  biliary  passages  is  almost 
always  at  the  fundus  of  the  gall-bladder,  but  occasionally,  as 
in  a  case  reported  by  Frerichs,  it  is  in  the  common  bile-duct ; ' 
that  in  the  duodenum  is  in  its  third  or  lowest  division.  The  size 
of  the  opening  varies  according  to  that  of  the  stone  which 
has  been  transmitted,  and  to  the  period  which  has  elapsed 
between  that  occurrence  and  death.  The  symptoms  attend- 
ing the  formation  of  these  fistulee  are  sometimes  obscure. 
Those  which  have  been  noted  consist  mainly  in  vomit- 
ing, with  signs  of  local  peritonitis  in  the  region  of  the  gall- 
bladder. Frerichs  in  one  of  his  cases  observed  hsematemesis 
and  bloody  stools.  Jaundice  is  rarely  present,  for  though  the 
cystic  duct  may  be  obstructed,  the  common  duct  is  usually 
free.  It  is  only  occasionally  that  the  diagnosis  will  be  assisted 
by  a  previous  history  of  gall-stone  colic  with  jaundice.  After 
the  formation  of  the  fistula,  there  may  be  nothing  to  indicate 
its  existence.  Unless  the  gall-stone  be  lai-ge  enough  to  cause 
obstruction  of  the  bowels,  the  fistula  may  cause  no  symptoms 
of  importance  and  a  biliary  calculus  may  be  passed  from  the 
bowel  with  little  trouble,  which  by  the  route  of  the  bile-duct 
•would  have  caused  tremendous  suffering ;  and  thus  we  have  an 
explanation  of  a  statement  of  certain  early  writers,  to  the 
effect  that  small  gall-stones  cause  more  pain  in  their  escape 
from  the  body  than  large  ones.  But  if  there  be  permanent 
obstruction  of  the  common  duct  and  the  cystic  duct  be  free, 
the  jaundice  which  has  existed  pi'ior  to  the  fistula  will  disap- 
pear, and  the  motions,  unless  there  be  obstruction  of  the  bowels, 
will  contain  bile.  Thus  in  Trousseau's  case  bile  escaped  through 
the  fistula  into  the  bowel  after  the  common  bile-duct  had  be- 
come obliterated.  In  many  cases  no  doubt  the  fistula  closes, 
as  in  Case  LXXI.  (p.  174). 

c.  Fistulw  into  the  Colon  from  gall-stones  are  comparatively 
rare.  Frerichs,  Oppolzer,  and  all  writers  of  authority  agree 
in  this  statement.  The  exemption  of  the  colon,  as  compared 
with  the  duodenum  in  this  respect,  is  probably  due  to  the 
former  bowel  being  more  movable.  I  have  been  able  to  find  the 
records  of  only  nine  cases  of  fistuUe  between  the  gall-bladder 
and  colon.     In  six  of  the  nine  there  was  cancer  of  the  gall- 

»  Op.  cit.  ii.  540. 


LECT.  xiii.  THEIR   CONSEQUENCES    AND    SYMPTOMS.  499 

bladder,'  one  of  tlie  six  cases  occurred  in  my  own  practice 
(Case  CLXXVI.).  Of  the  three  remaining  cases,  one,  in  which 
the  fistula  probably  resulted  from  the  passage  of  a  gall-stone,  is 
recorded  at  page  511  (Case  CLXVIII.).  A  second  is  reporte<l 
by  Dr.  J.  W.  Ogle.^  The  specimen  of  the  third  case  is  pre- 
served in  the  Museum  of  St.  Bartholomew's  Hospital  ;  ^  here 
there  were  two  fistulse,  one  into  the  small  intestine,  the  other  into 
the  colon  :  a  large  calculus  had  passed  through  the  former  into 
the  ileum,  and  another,  also  large,  into  the  colon  and  was 
found  in  the  caecum.  In  the  body  of  a  patient  who  died  in 
this  (Middlesex)  hospital  some  years  ago,  I  found  what  was^ 
probably  a  similar  condition  in  a  more  advanced  stage ;  the 
gall-bladder  communicated  with  the  duodenum,  the- colon,  and 
the  external  surface ;  there  was  no  cancer,  but  the  origin  of 
the  disease  was  probably  a  gall-stone  (Case  CLXXI.).^  But  even 
when  the  fistula  is  cancerous  it  is  probable  that  the  ulcerative 
process  leading  to  its  formation  is  determined  by  gall-stones. 
In  my  own  case  there  had  been  a  previous  history  of  gall- 
stone colic  and  jaundice,  and  in  four  of  the  remaining  five 
cases  gall-stones  were  found..  In  a  specimen  in  the  Museum  at 
Boston,  U.S.,  the  patient,. after  symptoms  of  obstructed  bowels, 
voided  per  anum,  three  months  before  death,  a  biliary  calculus 
measuring  3|  in.  hy  3'.  in.  in  circumference,  and  the  signs 
of  cancer  did  not  show  themselves  till  two  months  later. 
Of  11  cases  of  cancer  of  the  gall-bladder  collected  by  Frerichs, 
gall-stones  were  present  in  9.  The  symptoms  of  cystico-colic 
fistula  will  be  mainly  those  of  the  cancerous  disease  with  which 
it  seems  to  be  usually  associated.  A  simple  cystico-colic  fistula 
might  be  expected  to  cause  less  disturbance  than  a  cystico-duo- 
denal,  as  there  would  be  less  risk  of  a  large  calculus  becoming 
impacted  in  the  large  bowel  than  in  the  small.  Its  existence- 
might  be   so  little  suspected  during  life,  that  possibly  it  has 

'  Two  cases  ty  Fauconneau-Dufresne,  op;  cit.  p.  338  ;  one  by  Burrard-FarJel. 
Frerichs,  op.  cit.  p.  4&0;  one  by  Cruveilhier,  Traits  dMnat.  Path.  ii.  543;  one  by 
Murchison  (see  Case  CLXXVI.,  p.  528) ;  one  specimen  in  Mus.  of  Med..  Soc.  of  Bo.ston, 
US.  No.  565.  I  have  found  only  one  jn«tiince  of  a  cancerous  fistula  between  the  gall- 
bladder and  duodenum,  and  there  also  the  opening  was  closed  by  a  calculus.  Cru- 
veilhier, op.  cit.  ii.  543. 

=^  St.  George's  Hosp.  Eep.  vol.  iii.  p.  178. 

3  Ser.  xvi.  No.  84. 

*  Dr.  Bristowe  has  reconled  a  somewhat  similar  case  where  the  common  bile-duct, 
in  consequence  of  obstruction  from  gall-stones,  communicated  with  the  duodenum,  the 
colon,  and  the  portal  vein.     (Path.  Trans,  vol,  ix.  p.  285.) 

K  K   2 


500  GALL-STONES  :  tECT.  xiii. 

been  sometimes  overlooked  after  death,  and  its  occurrence  may- 
be more  common  than  is  supposed.  (See  Case  CLXIX.) 

d.  FistuloB  into  the  Urinary  Passages. — There  are  at  least  two 
well-authenticated  cases  on  record  where  biliary  calculi  have 
been  voided  with  the  urine  during  life,  apparently  owing  to 
the  formation  of  a  fistula  between  the  gall-bladder  and  the 
pelvis  of  the  right  kidney.'  One  of  the  patients  passed  nine 
small  and  four  large  calculi ;  the  other  voided  200  small  calculi 
within  a  week  :  in  both  patients  an  operation  was  necessary  to 
remove  one  of  the  calculi  from  the  urethra.  In  both  cases  the 
calculi  were  analysed  and  found  to  consist  of  cholesterin  and  bile- 
pigment  ;  and  in  one  the  analysis  was  made  by  Gmelin,  who  also 
found  bile-pigment  in  the  urine.  Neither  of  the  patients  had  ever 
had  jaundice ;  in  both  the  symptoms  were  those  of  urinary  rather 
than  of  hepatic  disease ;  both  recovered.  In  connection  with 
this  subject  I  may  call  your  attention  to  the  case  of  a 
patient  who  recently  died  of  calculous  pyelitis  while  under  my 
care  in  the  hospital,  and  whose  urine  always  contained  a  large 
quantity  of  cholesterin  and  pus,  although  no  communication 
existed  between  the  urinary  and  biliai'y  passages.^ 

e.  Fistulce  into  the  Vagina. — The  onl}^  instance  with  which 
I  am  acquainted  where  a  fistula  formed  between  the  biliary 
passages  and  the  vagina  is  one  quoted  from  Frank  by  Faucon- 
neau-Dufresne,  where  an  enlarged  and  inflamed  gall-bladder 
contracted  adhesions  to  a  pregnant  uterus  and  burst  into  the 
vagina  during  parturition.^ 

/.  FistiilcB  into  the  Portal  Vein. — It  is  a  tradition  that  Real- 
dus  Columbus  found  three  gall-stones  in  the  portal  vein  of 
Ignatius  Loyola,  the  founder  of  the  order  of  the  Jesuits,  which 
had  escaped  from  the  gall-bladder  by  ulceration  :  ■*  but  although 
it  may  be  doubled  whether  the  concretions  in  that  instance 
were  not  phlebolites,'^  there  are  several  well-authenticated  ex- 
amples of  fistulous  communications  between  the  biliary  pas- 
sages and  the  portal  vein,  Avith  the  presence  in  the  latter  of 
biliary  conci'etions.  Two  such  cases  are  referred  to  by  Fau- 
conneau-Dufresne  ^  and  Frerichs ;  a  third  is  recorded  by  Dr. 
Bristowe  in  the  Pathological  Transactions  (vol.  ix.  p.  285), 
where  the  common  bile-duct  also  opened  into  a  cavity  which 

\       '   FHUconiKMUi-Dufrcsno,  op.  cit.  p.  341,  ainl  Gaz.  Mud.  de  Paris,  Av.  18,  1840. 

*  Tliis  case  is  recorded  in  tlie  Pathological  Transactions,  vol.  xix.  p.  278. 

*  I'aucoinnviu-Dufrcsno,  op.  cit.  p.  l.j'.).  *  Frerichs,  op.  cit.  ii.  526. 

*  Thudichum  un  Uall-stouus,  J8G3,  pp.  11,  2W,  *  Op.  cit.  p.  340. 


lECT.  xm.  THEIR   CONSEQUENCES    AND    SYMPTOMS.  5OI 

communicated  both  with  the  duodenum  and  the  colon  ;  a  fourth 
case  has  come  under  my  own  observation  (Case  CLXXIV.). 
In  these  cases  the  common  bile-duct  is  usually  obstructed  by 
a  concretion,  and  the  symptoms  are  those  of  portal  obstruc- 
tion— ascites  or  enlargement  of  the  spleen,  or  both, — or  of 
pyaemia,  supervening  upon  persistent  jaundice. 

g.  FistulcB  into  the  Pleura. — One  instance  is  on  record  of  a 
fistulous  communication  between  the  biliary  passages  and  the 
pleura.  This  lesion  was  discovered  by  Dr.  Cayley  in  the  body 
of  a  patient  who  died  in  the  Middlesex  Hospital  on  March  2, 
1866,  while  under  the  care  of  Dr.  Thompson,  and  whose  case 
is  reported  in  the  Pathological  Transactions  (vol.  xvii.  p.  161). 
All  of  the  bile-ducts  were  enormously  dilated,  apparently  in 
consequence  of  a  gall-stone  which  had  been  impacted  in  the 
common  duct,  but  which  had  escaped  into  the  bowel  before 
death.  The  common  duct  would  allow  the  fore-finger  to  be 
introduced  into  it  from  the  duodenum.  The  left  pleural  cavity 
contained  more  than  a  pint  of  bile  mixed  with  pus,  and  in  the 
left  half  of  the  diaphragm  there  was  a  perforation  large  enough 
to  admit  a  ISTo.  4  catheter  which  led  into  an  irregular  cavity 
between  the  left  lobe  of  the  liver  and  the  under  surface  of  the 
diaphragm,  which  _  in  its  turn  communicated  with  a  cystic 
dilatation  of  one  of  the  bile-ducts  in  the  liver.  The  case  was 
also  remarkable  from  the  fact  that  there  was  no  evidence  of 
obstruction  of  the  bile-duct  until  fifteen  days  before  death,  and 
that  there  were  both  the  symptoms  and  the  post-mortem  ap- 
pearances of  acute  or  yellow  atrophy  of  the  liver. 

12.  Gall-stones  may  he  discharged  from  the  biliary  passages 
through  fistulous  openings  in  the  abdominal  parietes. — The  ten 
gall-stones  which  are  in  this  bottle  were  discharged  through 
an  opening  in  the  abdominal  wall  by  a  lady  who  has  been  for 
several  years  under  my  care  (Case  CLXX.)  ;  and  I  find  that  in 
medical  literature  and  in  pathological  museums  there  are  the 
records  or  the  relics  of  at  least  86   similar  cases,  ^  which,  with 

1  Six  cases  observed  or  collected  by  J.  L.  Petit,  M^m.  de  I'Acad.  Eoy.  deChir.  1743, 
ome  i.  p.  255  ;  one  by  Haller,  Physiologia,  Berne,  1764,  tome  vi.  p.  605  ;  eleven  cases  by 
Soemmering,  De  concrementis  biliariis  corporis  humani,  1795,  p.  20  :  one  by  Saun- 
ders, Trans,  of  Coll.  of  Phys. ;  seventeen  cases  by  Fauconneau-Diifresne,  exclusive  of 
three  cases  already  reported  by  Petit,  Mem.  de  I'Acad  de  Med.  1847,  xiii.  320  and 
167  ;  three  cases  by  Oppolzer,  Zeits.  der  Gesellsch.  der  Aerzte  in  Wien,  Nov.  1860, 
p.  747  ;  three  cases  by  AValter,  Frerichs  on  Dis.  of  Liver,  Eng.  ed.  ii.  525 ;  three  cases  by 
Budd,  Dis.  of  Liver,  3rd  ed.  p.  373  ;  three  cases  in  Gazette  des  Hopitaux,  1846,  Oct. 
8,  and  1847,  p.  212;  two  by  Cruveilhier,  Traite  d'Anat.  Path.  ii.  567,  670;  two  by 


502  GALL-STONES  :  lect.  xiii. 

few  exceptions,  have  occurred  in  females  of  middle  or  advanced 
age.  No  fewer  than  five  have  come  under  my  own  observa- 
tion. These  fistulous  openings  are  formed  in  two  ways.  In 
some  cases  the  ulcerative  process  which  commences  in  the  gall- 
bladder or  in  a  dilated  duct  gradually  eats  its  way  through 
the  adherent  abdominal  wall  until  it  reaches  the  surface,  while 
in  others  the  gall-bladder  or  one  of  the  bile-ducts  becomes  in 
the  first  place  enormously  enlarged  from  the  accumulation  of 
infiammatory  products  and  opens. externally,  or, being  often  mis- 
taken for  an  abscess  of  the  liver,  is  opened  by  the  surgeon.  The 
external  opening  is  sometimes  over  the  fundus  of  the  gall-bladder, 
but  very  frequently  it  is  at  the  umbilicus,  to  which  it  may  be 
directed  by  the  suspensory  ligament  of  the  liver ;  occasionally 
it  is  to  the  left  of  the  middle  line,  or  in  the  inguinal  region,  or 
over  the  pubes  as  in  a  case  observed  some  years  ago  at  Paris 
in  which  two  biliary  calculi  were  removed  from  above  the 
clitoris,  where  they  had  been  encysted  in  die  subcutaneous 
tissue.'  In  rare  cases  there  are  two  or  more  openings.  The 
number  of  gall-stones  discharged  by  the  opening  varies  from 
one  to  upwards  of  600.  When  there  is  only  one,  it  may  be  as 
large  as  a  hen's  egg.  Faucoinieau-Dufresne  refers  to  one 
which  measured  3'15  in.  in  length  by  1*1  in.  in  width. 
Calculi  may  be  discharged  almost  as  soon  as  the  opening  ia 
formed,  or  not  for  years  afterwards.  The  fistula  has  been 
known  to  keep  discharging  for  many  months  after  all  the  cal- 
culi have  come  away,  but  usually  it  soon  closes  after  this  has 
occurred,  if  there  be  no  bile  in  the  discharge.     The  fluid  which 


TrousHcau,  Clin.  Med.  ii.  584  ;  two  l>y  Diiplay  ami  I'letin  in  Archiv.  Gi'n.  de  M('d. 
2mo  .sur.  i.  381,  and  5me  ser.  iv.  86  ;  one  by  Obrc,  Path.  Tran.s.  of  Lond.  i.  272  :  oiio 
by  Simon,  ib.  v.  156 ;  one  by  R.  Robinson,  ib.  v.  158  ;  one  by  Everet,  ib.  xviii.  120 ; 
one  by  Taylor,  ib.  xviii.  147  ;  one  by  Duckworth,  ib.  xxii.  157;  one  by  Heberdcii, 
Comment.  4th  ed.  p.  210  ;  one  l)y  Santo-Nubili,  .Sclunidt's  Jahrb.  Iviii.  62,  1848  ;  one 
by  .S<'hroeder,  Prag.  Vierteljahrs.  xliv.  .Sup.  p.  70,  1854;  one  by  Callaway,  Lancet, 
1827-8,  ii.  296;  one  by  H.  C.  Stewart,  ib.  1849,  ii.  294;  one  by  Nesfield,  ib.  1870.  i. 
157;  one  by  W.  R.  Barlow,  Med.  Cliir.  Tran.s.  vol.  xxvii.  ;  one  by  G.  Robinson,  ib. 
vol.  XXXV.  1852,  p.  471  ;  one  by  Mackindur,  Ri-it.  Med.  Journ.  Dee.  26,  1857;  one  by 
llinton,  ib.  Aug.  4,  1860;  one  by  Dr.  G.  H.  Pliillip.son,  ib.  1870,  ii.  382;  one  by 
Alexander,  ib.  1876,  ii.  397  ;  one  by  Cockle,  Mwl.  Times  and  Gazette,  May  10,  1862  ; 
one  by  Dr.  II.  liaillio,  Ind.  Ann.  of  Med.  .Se..  vol.  xii.  p.  295  ;  one  by  Hertz,  Rnrlimr 
Klin.  WochenHchrift,  Ap.  7,  1873;  one  by  Krumptmaiui,  Lond.  J\Ied.  Record,  A  p.  30, 
1873  :  five  by  Murchi.son  (see  p.  520);  three  sj^ccimcns  in  Mus.  Hoy.  Coll.  Surg.  Cat. 
of  the  Calculi,  pp.  17"^',  176,  178;  one  in  Mus.  of  Med.  Soc.  of  Boston,  U.S.  No.  566; 
one  by  McPherson,  Amer.  Journ.  of  Mi'd.  Sc.  vol.  Ixi.  p.  40J. 
»  Gaz.  des  Hop.  Oct.  8,  1846. 


LECT.  XIII.  THEIE    CONSEQUENCES    AND    SYMPTOMS.  503 

drains  away  from  the  fistula  may  be  pure  bile,  the  daily  quan- 
tity of  which  has  been  found  to  vary  from  8  oz.  to  2  pints. ^ 
Far  more  commonly  it  is  pure  pus,  or  a  glairy  mucus  with  now 
and  then  a  little  blood.  In  most  cases  the  cystic  duct  is  ob- 
structed and  then  no  bile  can  escape  by  the  fistula ;  in  a  few 
cases  the  common  duct  only  is  obstructed,  and  then  the  jaun- 
dice caused  by  this  obstruction  disappears  in  a  great  measure 
on  the  formation  of  the  fistula,  although  no  bile  is  present  in 
the  stools ;  in  rare  cases  the  gall-ducts  are  patent  and  bile 
passes  ofi"  both  by  the  fistula  and  the  bowels.  After  the  dis- 
charge of  a  gall-stone  the  external  opening  rapidly  contracts 
and  is  drawn  inwards,  while  the  fistulous  passage  connecting 
it  with  the  gall-bladder  may  be  several  inches  in  length  and 
may  also  be  extremely  tortuous  and  surrounded  with  callous 
induration.  Not  unfrequently  gall-stones  become  lodged  in  a 
cul  de  sac  of  the  fistula,  or  may  completely  obstruct  it  and  lead 
to  the  accumulation  of  matter  behind  and  the  formation  of 
fresh  abscesses.  The  adhesions  between  the  gall-bladder  and 
the  abdominal  parietes  may  be  very  extensive,  but  are  often 
very  limited.  These  fistulous  openings  are  chiefly  serious 
from  the  inconvenience  which  they  occasion.  A  large  propor- 
tion of  the  patients  survive  their  formation  for  years  and  enjoy 
good  health,  and  in  many  the  fistulse  completely  heal.-^  This 
last  event  may  be  predicted  with  most  confidence  when  there 
is  only  one  large  calculus,  when  the  external  opening  is  directly 
over  the  gall-bladder,  when  the  discharge  from  it  contains  no 
bile,  and  when  there  is  no  jaundice.  There  is  little  hope  of 
the  fistula  permanently  closing  while  calculi  still  remain  in 
the  gall-bladder,  or  if  the  cystic  duct  be  patent  while  the 
common  duct  is  closed.  In  cases  where  the  quantity  of  bile 
lost  is  great,  which  are  happily  rare,  the  patient  may  become 
rapidly  reduced  in  fiesh  and  strength  and  die  of  marasmus. 
When  the  calculi  are  many  in  number,  and  the  fistula  is  long, 
tortuous,  and  surrounded  by  callous  tissue,  the  openings  though 
small,  may  continue  for  years,  showing  every  now  and  then  a 


'  Fauconneau-Dufresne,  op.  cit.  p.  323  ;  and  cases  by  Haller,  Heberden,  Saunders, 
"Barlow,  Eobinson,  Hertz,  and  Kruniptmann.  For  references,  see  footnote,  p.  501. 
Also  Case  CLXXII. 

^  A  case  has  been  communicated  to  me  by  Mr.  James  Taylor  of  Chester  in  which 
the  fistula  became  permanently  closed  after  ten  weeks.  The  patient,  a  female  aged 
53,  had  suffered  from  several  typical  attacks  of  biliary  colic  before  the  formation  of 
the  abscess  in  the  gall-bladder,  which  was  opened  artificially. 


504  GALL-STONES  :  lect.  xiii. 

tendency  to  cicatrise,  but  again  enlarging  on  the  escape  of  a 
fresh  calculus,  the  passage  of  which  often  entails  much  suffer- 
ing, although  in  the  intervals  the  patient  enjoys  good  health. 

From  this  lengthened  list  of  the  evils  of  which  gall-stones 
may  be  the  source,  you  will  learn  to  avoid  the  common  error 
of  regarding  them  as  a  harmless,  though  perhaps  painful, 
malady,  and  you  will  see  the  necessity  in  all  cases  of  being 
guarded  in  your  prognosis. 

Treatment  of  the  consequences  of  Gall-stones. 

1.  When  the  symptoms  indicate  the  presence  of  gall-stones 
in  the  gall-bladder,  the  treatment  must  consist  in  those  con- 
stitutional measures  which  I  have  already  told  you  are  useful 
for  gall-stones  in  general  (p.  362),  and  in  remedies  for  correct- 
ing any  symptoms  of  indigestion.  At  the  same  time  the  pa- 
tient should  be  cautioned  as  to  the  risk  of  a  gall-stone  being 
projected  into  the  bile-ducts  by  sudden  or  severe  muscular 
exertion,  or  by  driving  over  a  rough  road,  especially  after 
meals. 

2.  The  measures  to  be  adopted  when  gall-stones  are  in  the 
ducts  have  alread}'  been  described  to  you  in  detail  (p.  360). 
When  there  is  reason  to  believe  that  the  calculus  has  entered 
the  bowel,  it  is  well  to  administer  some  laxative  such  as  castor 
oil,  with  the  object  of  expediting  its  j)assage  to  the  anus. 

3.  When  symptoms  of  inflamed  gall-bladder — fever  with 
pain,  tenderness,  and  often  a  distinct  tumour — supervene  upon 
those  of  gall-stones  in  the  ducts,  the  treatment  may  be 
summed  up  in  the  three  words  which  I  mention  in  the  order 
of  their  importance,  viz.  : — rest,  opium,  and  leeches.  Rest  is 
all-important  to  promote  the  formation  of  adhesions  and  prevent 
the  extension  of  the  inflammation  to  the  general  cavity  of  the 
peritoneum.  Any  sudden  movement  may  produce  a  rupture  in 
the  inflamed  and  softened  gall-bladder  and  fatal  peritonitis  in 
consequence.  Opium  may  be  given  in  large  and  repeated 
doses,  and  I  have  often  known  the  pain  materially  relieved  by 
the  application  of  a  few  leeches  below  the  right  ribs.  The 
expediency  of  puncturing  the  gall-bladder,  when  it  is  very 
large,  will  be  considered  presently. 

4.  When  symptoms  of  gall-stones  in  the  gall-bladder  or 
ducts,  or  of  inflammation  of  the  gall-bladder,  are  followed  by 


LECT.  xm.  THEIR    CONSEQUENCES    AND    TREATMENT.  505 

those  of  ileus,  although  death  is  too  often  the  result,  recovery 
after  the  expulsion  of  a  large  calculus  per  anum  has  been 
sufficiently  frequent  to  justify  us  in  sparing  no  effort  for  the 
attainment  of  this  desirable  end.  Warm  baths  and  fomentations, 
opium  and  belladonna  in  full  and  repeated  doses,  and  copious 
enemata  of  warm  water  and  oil  are  the  measures  most  to  be 
relied  on.  Gentle  pressure  and  manipulation  of  the  abdomen 
have  been  thought  in  some  instances  to  have  displaced  the 
stone.  Sir  Thomas  Watson  relates  how  a  lady  suffering  from 
ileus  experienced  a  sensation  as  if  this  had  occurred  during 
her  examination  by  three  medical  men  in  succession ;  while 
they  were  still  consulting  she  had  a  liquid  motion  precisely  re- 
sembling what  she  had  last  vomited,  and  next  day  she  voided 
a  gall-stone  as  big  as  a  walnut.'  Lastly,  in  all  cases  where 
there  is  reason  to  believe  that  intestinal  obstruction  is  due  to 
biliary  concretions,  it  will  be  well  to  examine  the  rectum. 
Now  and  then  the  obstruction  is  situated  immediately  above 
the  S]3hincter  and  can  be  removed  by  the  finger  or  scoop. 

5.  Internal  biliary  fistulse  are  beyond  the  reach  of  medical 
or  surgical  art ;  but  those  into  the  intestines,  which  are  most 
common,  are  scarcely  dangerous  except  from  their  sometimes 
permitting  the  escape  of  a  calculus  large  enough  to  obstruct 
the  bowels. 

6.  When  external  biliary  fistulse  discharge  one  large 
rounded  calculus  without  facets,  and  the  outer  opening  is  over 
the  fundus  of  the  gall-bladder,  they  usually  heal  speedily  with- 
out any  interference.  But  when  the  gall-bladder  contains 
many  small  calculi,  and  still  more  when  the  fistula  is  long, 
narrow,  circuitous,  and  surrounded  by  callous  tissue,  the 
opening  may  remain  for  years  or  may  never  close,  and  every 
now  and  then  the  fistula  is  apt  to  become  blocked  up  by  a 
calculus,  the  passage  of  which  causes  much  pain  and  leads  to 
accumulation  of  matter  behind  it.  Under  these  circumstances, 
the  question  will  arise  as  to  the  expediency  of  dilating  or 
slitting  up  the  fistula  to  facilitate  the  extraction  of  the  calculi. 
This  has  been  done  in  many  cases  with  a  successful  result  ;^  but 
on  the  other  hand  there  are  several  instances  on  record,  where 
even  slight  interference,  such  as  the  introduction  of  a  dressing 
forceps,  has  brought  on  fatal  peritonitis.     There  is  no  general 

^  Lect.  on  Pract.  of  Physic,  5th  ed.  ii.  549. 

*  See,  for  instance,  a  case  reported  by  Dr.  H.  Baillie,  in  which  15  gall-stones  were 
removed  by  operation.     Indian  Annals  of  Med.  Science,  xii.  296. 


5CC  GALL-STONES  : 


LECT.    XIII. 


rule  applicable  to  all  of  these  cases,  but  the  question  of  ope- 
rating must  be  decided  by  the  peculiarities  of  each  case.  If,  on 
probing,  a  calculus  can  be  felt  near  the  outer  opening  and  is 
long  delayed  there,  it  ought  to  be  extracted  ;  but  if  no  calculus 
can  be  felt,  and  still  more  if  the  fistula  take  an  inward  direction 
towards  the  peritoneum,  the  risk  of  interference  ought  to 
counterbalance  the  inconvenience  of  the  fistula,  and  it  is  better 
to  wait.  When  pure  bile  drains  away  in  large  quantity  from 
the  opening  and  none  enters  the  bowel,  there  is  little  chance  of 
the  fistula  closing,  and  it  is  not  desirable  that  it  should,  unless, 
as  in  Case  CLXXIL  the  obstruction  of  the  common  duct  were 
simultaneously  removed ;  but  if  the  common  bile-duct  be  patent, 
and  the  patient  suffer  from  the  exhaustion  consequent  on  the 
external  drain  of  bile,  the  question  of  closing  the  fistula  may 
fairly  be  entertained. 

In  illustration  of  some  of  these  evil  consequences  of  gall- 
stones, I  may  now  bring  under  your  notice  the  following 
cases : — 

Cask  CLXV. — Gall-stones  in  a  Sacculus  of  Common  Bile-duct  and  in 
Gall-bladder — Ulceration  and  Perforation  of  Gall-bladder — Fatal 
Peritonitis. 

Mrs.  C ,  aged  55,  bad  consnlted  me  repeatedly  during  three 

years  for  noises  in  head  and  other  distressing  nervous  symptoms, 
which  first  appeared  after  a  period  of  great  mental  anxiety,  and  which 
conhl  onl}^  he  accounted  for  by  a  weak  state  of  circulation,  with 
probably  a  fatty  heart.  She  had  in  consequence  taken  but  little 
exercise,  and  spent  a  great  part  of  her  time  in  bed.  About  end  of 
May  1867  I  was  called  to  see  her,  and  found  that  she  had  decided 
jaundice  of  skin  and  conjunctivae,  and  that  urine  contained  a  con- 
siderable amount  of  bile-pigment.  Liver  also  was  slightly  enlarged. 
For  two  or  three  days  she  had  been  sufferini^  from  paroxysms  of  severe 
pain  in  right  hypochondrium  with  vomiting.  A  feeling  of  soreness 
remained  in  intervals  of  paroxysms  and  there  was  slight  tenderness 
below  right  ribs.  Pulse,  however,  only  72,  and  skin  cool.  Under  use 
of  warm  fomentations,  repeated  doses  of  morphia  and  laxatives,  the 
acute  symptoms  subsided  in  a  few  days ;  by  end  of  a  fortnight,  jaun- 
dice had  disappeared  and  patient  was  able  to  go  out. 

On  June  24  she  had  a  return  of  severe  pain  in  abdomen.  When 
I  saw  her  on  2Gth  she  was  again  jaundiced  and  her  symptoms  differed 
from  those  in  previous  attack  in  that  j)ulse  was  06,  skin  felt  slightly 
liot,  and  there  was  rather  more  tenderness  below  right  ribs,  with 
tendency  to   hiccough.     Still   pain  was  for  most  part  paroxysmal  and 


tECT.  XIII.  THEIR    CONSEQUENCES    AND    SYMPTOMS.  50/ 

relief  was  again  obtained  from  morphia.  For  two  clays  slie  seemed  to 
improve,  but  on  night  of  28th  she  became  rather  suddenly  worse  and 
at  my  visit  on  following  day  she  had  all  the  symptoms  of  acute  peri- 
tonitis :  pulse  136,  small  and  feeble ;  respirations  short,  quick,  and 
thoracic  ;  constant  vomiting  and  hiccough  ;  abdomen  greatly  distended 
and  tympanitic,  and  acute  pain  and  tenderness,  chiefly  in  left  side — 
constant  and  aggravated  by  slightest  movement.  From  this  time 
patient  continued  to  sink  until  death  occurred  on  night  of  July  12. 

At  post-mortem  examination  two  openings  were  found  in  fundus  of 
gall-bladder,  both  with  ragged  edges  and  one  large  enough  to  admit 
linger.  Through  these  openings  bile  had  escaped  in  large  quantity 
into  peritoneum.  Firm  adhesions  of  great  omentum  to  abdominal  wall 
had  directed  bile  entirely  to  left  side  of  abdomen,  where  there  were 
signs  of  recent  peritonitis — intense  vascular  injection  and  lymph 
coloured  with  bile.  Mucous  surface  of  gall-bladder  surrounding 
openings  was  extensively  ulcerated,  apparently  from  pressure  of  a  gall- 
stone, size  of  a  cherry,  which  v^^as  in  immediate  apposition  and  had 
not  escaped  into  peritoneum.  Common  bile-duct  communicated  with 
a  pouch  as  large  as  a  hen's  egg,  containing  bile  and  upwards  of  a 
dozen  polyhedral  gall-stones,  each  about  size  of  half  a  cherry  ;  but  no 
concretion  was  found  obstructing  duct  between  pouch  and  duodenum. 
No  abscesses  in  liver.  Heart,  kidneys,  and  liver  in  a  state  of  fatty 
degeneration. 

Case  CLXVI. — Fistulous  Opening  betu-een  Gall-bladder  and  Duodenum — 
Fatal  Obstruction  of  Small  Intestine  by  a  large  Biliary  Calculus. 

A.   McD ,   aged   46,  was    admitted   into    Middlesex   Hospital 

under  care  of  Dr.  Stewart,  on  Jan.  29,  1856.  Her  general  health 
had  been  good,  but  for  many  years  past  she  had  been  of  a  costive 
habit,  bowels  being  seldom  moved  without  taking  aperient  pills.  She 
had  been  subject  to  bilious  attacks  with  vomiting  of  green  bitter 
matter,  and  to  loss  of  appetite  with  excessive  flatulence  after  meals, 
but  she  never  had  jaundice. 

Twelve  days  before  admission  she  took  two  '  antibilious  pills,' 
which  acted  freely  on  following  day.  Vomiting  took  place  at  same 
time  and  continued  with  little  intermission  ever  afterwards.  Motions 
and  vomited  matters  were  of  a  green  colour.  Sleep  much  disturbed. 
Two  days  after  this  she  was  suddenly  seized  with  a  severe,  sharp  pain 
in  right  iliac  region,  where  tenderness  on  pressure  was  still  acute ; 
this  pain  continued  with  remissions  until  time  of  admission.  She  had 
no  motion  for  ten  days  from  that  time,  i.e.  from  the  19th  to  the  29th 
of  January. 

On  admission,  an  injection  consisting  of  a  pint  of  gruel  and  some 
castor  oil  was  administered.  The  whole  of  it  passed  up,  but  it  caused 
great  pain  and  was  soon  discharged  with  several  large  hard  scybalous 
masses.     The   abdomen  then  became  flaccid ;  it  was  slightly  dull  to 


508  GALL-STONES 


LECT.    XIII. 


right  of  umbilicus,  but  elsewhere  perfectly  resonant.  Her  countenance 
was  somewhat  pinched  and  anxions  and  cheeks  flushed.  Tongne  dry 
and  covered  with  a  thick  yellow  fur  on  dorsum,  moist  and  clean  at 
edges  ;  thirst  very  urgent.  Pulse  80,  very  small.  Slight  sonorous 
rhonchi  on  right  side  of  chest ;  breathing  healthy  on  left  side.  Heart- 
sounds  normal.  A  warm  bath  was  ordered,  to  be  followed  by  poppy- 
head  fomentations  to  abdomen  and  an  opiate  pill. 

Jan.  30. — Passed  a  tolerable  night,  and  notwithstanding  a  constant 
sensation  of  nausea  has  not  vomited  since  admission.  Two  pints  of 
injection  passed  up  without  difficulty  or  pain,  but  after  being  retained 
half  an  hour  returned  without  a  trace  of  faeculent  matter.  Abdomen 
is  now  much  more  tense  and  tympanitic  and  is  still  painful  on 
pressure. 

10  P.M. — Countenance  less  anxious;  thirst  very  great;  nausea 
continues,  but  she  has  not  vomited  until  just  now,  when  she  suddenly 
raised  herself  on  elbow  and  vomited  more  than  half  a  pint  of  dark 
brown  and  very  offensive  stercoraceous  fluid  ;  retching  continued  for 
several  minutes  until  she  had  brought  up  about  tliree  pints  of  this 
fetid  fluid.     Pulse  78. 

Jan.  31. —  There  was  no  recui'rence  of  vomiting  till  11  a.m.,  when 
she  vomited  about  a  pint  of  fluid  having  same  colour,  but  without 
fasculent  odour  of  that  brought  up  yesterday.  Abdomen  became  more 
and  more  distended ;  pain  increased  ;  no  motion  passed  ;  there  was 
frequent  retching  ;  exhaustion  supervened,  and  she  died  rather  suddenly 
this  evening. 

Atdopsy. — Intestines  much  distended  and  in  some  places  adherent 
to  each  other  by  recent  lymph  ;  great  omentum  puckered  up  and 
adherent  to  intestines.  On  separating  intestines,  a  solid  body  about 
size  and  shape  of  a  cork  was  found  to  block  up  small  intestine,  about 
middle  of  ileum,  which  it  fitted  like  a  plug.  At  point  of  obstruction 
gut  was  bent  upon  itself,  adjacent  peritoneal  surfaces  being  slightly 
adherent  by  recent  lymph.  Intestine  seemed  to  become  suddenly 
smaller  immediately  below  obstruction,  but  above  this  7)oint  it  was 
greatly  distended  and  filled  with  dark,  greenish,  faeculent  matter,  in 
which  were  found  ten  small  angular,  biliary  calculi,  of  about  half  size 
of  hazel-nuts  ;  dilated  portion  of  intestine  was  dark,  and  when  laid 
open  mucous  membrane  was  found  much  congested  and  in  some  parts 
coated  with  adherent  false  membrane  ;  a  number  of  small  roundish 
nlcers  were  scattered  over  surface.  Obstructing  body  was  discovered 
to  be  a  large  biliary  calculus.  It  was  perfectly  cylindrical,  measuring 
nearly  four  inches  in  circumference,  and  one  inch  and  a  quarter  in 
diameter.  Its  external  surface  was  uniformly  nodulated,  the  ex- 
tremities being  rather  smooth.  When  divided  transversely  it  exhibited 
a  crystalline  appearance. 

Below  obstruction  intestine  much  contracted  and  pale  throughout, 
containing  only  a  little  thickish  mucus  ;  colon  almost  empty.     Stomach 


LFX'T.  Sill.  THEIR    CONSEQUENCES    AND    SYMPTOMS.  5O9 

routained  some  greenish  faeculent  matter  and  one  small  angular  biliary 
calculus.  Gall-bladder  firmly  adherent  to  duodenum  at  point  where  it 
turns  down  to  become  perpendicular,  and  a  well-defined  communication 
existed  between  these  two  parts,  large  enough  to  admit  a  finger  easily. 
Gall-bladder  contracted  and  converted  into  a  small  fibrous  pouch ; 
there  could  be  no  doubt  that  calculi  had  passed  through  this  perforation, 
although  opening  was  now  much  smaller  than  calculus  causing  ob- 
struction. Common  bile-duct  patent  but  not  dilated ;  cystic  duct 
closed.  Liver  weighed  58  oz.  and  appeared  tolerably  healthy,  though 
rather  dark.     Heart,  lungs,  and  kidneys  not  diseased. 

In  the  next  case  it  is  tolerably  clear  that  the  small  bowel 
had  been  obstructed  for  ten  days  by  a  large  biliary  calculus 
which  had  escaped  by  perforation  of  the  gall-bladder  into  the 
duodenum,  but  that  the  obstruction  was  removed  and  the 
patient  lived  for  upwards  of  seven  years  afterwards.  This 
diagnosis  formed  during  life,  notwithstanding  that  the  faeces 
had  not  been  searched  for  a  stone,  was  verified  by  post-mortem 
examination.  In  reference  to  this  point  I  may  mention  the 
case  of  a  lady  who  brought  to  me  some  years  ago  a  gall- 
stone measuring  nearly  2  by  H  in.,  which  she  had  passed  per 
anum  after  symptoms  of  obstruction  and  inflammation  of  the 
bowels.  But  as  regards  diagnosis,  the  case  before  us  was  of 
even  greater  interest,  from  the  rare  conjunction  of  jaundice 
from,  obstruction  of  the  common  bile-ducts  by  gall-stones  with 
ascites  resulting  from  interstitial  hepatitis,  the  latter  being 
itself  a  result  of  the  irritation  set  up  by  gall-stones.  Ha.d  the 
patient  been  seen  for  the  first  time  in  an  advanced  stage  of  the 
malady,  with  no  accurate  knowledge  of  his  history,  the  existence 
of  a  tumour  would  have  been  the  most  legitimate  inference  from 
such  a  combination  of  symptoms  (see  p.  432).  The  formation 
of  gall-stones  within  the  bile-ducts,  after  obliteration  of  the 
gall-bladder,  is  also  worth}'  of  notice. 

Case  CLXVII. — JEscaj^e  of  Gall-stone  bij  Ulceration  from  Gall-hladder 
into  Duodenum — Obstruction  of  Bowel  for  ten  days — Recovery.  Death 
7\  years  after  from  Obstruction  of  Bile-dads  and  Ascites. 

On  Oct.  23, 1874,  Mr.  C ,  aged  'oQ,  consulted  me  at  the  request 

of  Dr.  Leech  of  Manchester.  Seven  years  before  he  had  an  attack  of 
obstruction  of  bowels,  which  lasted  ten  days  and  for  two  days  was 
attended  by  stercoraceous  vomiting,  but  which  ultimately  gave  way 
with  discharge  of  most  offensive  f^ces.  During  five  years  previous  to 
that  illness  he  had  several  attacks  of  very  severe  spasm,  commencing 
at  epigastrium  and  attended  by  retching.     After  the  attack  of  obstruc- 


510  GALL-STONES:  lect.  xiii. 

tion  of  bowels  he  recovered  and  attended  to  business,  but  the  paroxysms 
of  colic  recurred  from  time  to  time,  and  for  six  months  had  been  more 
frequent.  In  June  1874  he  became  for  first  time  jaundiced  and  he 
had  attacks  of  colic  once  or  twice  a  week,  attended  by  ricrors  and 
followed  by  fever  and  delirium,  the  pyrexia  (10o°)  subsiding  in 
perspiration  within  24  hours.  Each  attack  was  followed  by  a  marked 
increase  of  jaundice,  which  in  intervals  almost  faded  away.  Of  late 
these  attacks  had  been  less  frequent.  Motions  on  several  occasions 
had  been  searched  with  care,  but  no  gall-stone  had  ever  been  found. 

At  time  of  his  visit  to  me,  Mr.  C.  was  emaciated  and  had  distinct 
jaundice  of  a  bronzed  hue  ;  intense  itchiness  of  skin  preventing  sleep. 
Liver  not  enlai^ged ;  a  tender  spot,  but  no  prominence,  corresponding 
to  fundus  of  gall-bladder.  Much  bile-pigment  in  urine.  Diagnosis 
was  :  a  large  calculus  in  common  duct,  and  previous  attack  of  obstructed 
bowels,  probably  due  to  a  large  stone  which  had  escaped  by  ulceration 
into  duodenum. 

For  six  weeks  after  Mr.  C.  visited  me  he  seemed  somewhat  better 
and  he  continued  to  attend  to  business  ;  the  itchiness  remained  very 
troublesome,  but  attacks  of  pain  followed  by  rigors  and  fever  were  less 
frequent  and  severe.  On  Dec.  20  Dr.  L.  for  first  time  found  fluid  in 
abdominal  cavity,  and  a  week  later  there  was  oedema  of  legs.  Ascites 
and  a'dcaia  gradually  increased  and  strength  diminished  until  death 
on  Feb.  23,  1875.  During  last  six  weeks  of  life  there  was  no  fever 
and  but  little  pain.  A  week  before  death  Dr.  L.  removed  5  pints  of 
fluid  to  relieve  dyspnoea. 

Dr.  L.  has  kindly  furnished  me  with  an  account  of  appearances 
found  on  post-mortem  examination.  Several  quarts  of  serum  in  peri- 
toneum. Mesentery  and  coats  of  bowels  thickened  and  oedenuitous. 
Diaphragm  adherent  to  upper  surface  of  liver  in  front  part.  Trans- 
verse colon  adherent  to  under  surface  of  liver,  but  no  sign  of  ulcer  or 
cicati'ix  on  its  mucous  surface.  On  inner  surface  of  duodenum,  about 
2  in.  below  opening  of  bile-duct,  was  a  pouch,  at  bottom  of  which  was 
a  puckered  cicatrix  ;  this  corresj)onded  to  spot  where  duodenum  was 
adherent  to  liver.  Opening  of  connnon  bile-duct  in  duodenum  was 
distinct  and  of  natural  size  ;  but  outside  duodenal  wall  duct  was  enor- 
mously dilated  and  contained  a  light-bi-own  fluid  and  one  or  two  gall- 
stones, which  escaped  when  duct  was  cut  across  in  removing  liver. 
This  part  of  the  duct  would  easily  admit  a  tube  half  an  inch  in  diameter, 
but  just  where  it  entered  coats  of  bowel  it  suddenly  contracted  so  as 
to  admit  only  a  y)robe.  No  ap])earance  of  cicatrix  on  its  inner  surface. 
Gall-bladder  i-educed  to  size  of  a  large  nut;  cystic  duct  obliterated. 
Hepatic  ducts  in  interior  of  liver  greatly  dilated  and  contained  lo  gall- 
stones immersed  in  a  light-brown  fluid.  All  these  stones  had  facets  ; 
they  varied  in  size  from  a  hazel-nut  to  a  peppercorn  ;  largest  was 
Bitnated  just  where  hepatic  duct  entered  liver  ;  coats  of  ducts  thickened, 
but  free  from  ulceratiuu.     Walls  of  portal  vein  adjacent  to  dilated 


LECT.  XIII.  THEIR    CONSEQUENCES    AND    SYMPTOMS.  5  I  I 

ducts  also  thickened  and  red,  but  contained  no  blood-clots.  Liver 
small  and  iudui'ated ;  no  abscess  in  any  part  of  it.  Heart  and  lungs 
healthy. 

There  could  be  little  doubt  that  in  the  following'  case  the 
fistulous  communication  between  the  gall-bladder  and  the  colon 
had  resulted  from  the  passage  of  a  gall-stone.  Although  the 
patient  died  of  epithelioma  of  the  uterus,  there  was  no  sign  of 
any  new  growth  in  the  neighbourhood  of  the  fistula. 

Case   CLXVIII. — Fistulous  Communication  hetween  Gall-hladder  and 

Colon, 

A  woman,  set.  60,  died  in  Middlesex  Hosp.  on  Feb.  7,  1870.  She 
had  always  enjoyed  good  health  till  five  months  before  death,  when 
she  was  seized  with  severe  abdominal  pain,  coming  on  in  paroxysms, 
and  attended  by  nausea  and  retching.  She  kept  her  bed  for  two  davs, 
but  had  no  jaundice,  and  there  was  no  evidence  of  her  having  passed 
any  stone.  After  this  she  suffered  from  a  pain  in  the  uterine  region, 
and  the  immediate  cause  of  death  was  epithelial  cancer  of  the  uterus 
inducing  peritonitis. 

At  the  autopsy  the  gall  bladder  was  found  to  be  shrivelled  into 
little  more  than  a  duct ;  it  contained  a  little  mucus  not  tinged  with 
bile  ;  the  channel  of  the  cystic  duct  was  obliterated  and  the  fundus 
was  inseparably  adherent  to  the  transverse  colon,  with  which  it  com- 
municated by  a  circular  orifice,  with  smooth  well-defined  edges  and 
about  four  lines  in  diameter.  There  were  signs  of  old  inflammation 
about  the  fissure  of  the  liver,  the  capsule  of  which  was  thickened,  but 
the  outer  surface  was  smooth.  The  substance  of  the  liver  was  firm 
and  fibrous,  but  there  were  no  cancerous  masses  either  here  or  in  the 
neighbourhood  of  the  gall-bladder  or  colon. 

Notwithstanding  its  obscurity,  the  following  case  illustrates 
a  sequel  of  biliary  colic  to  which,  so  far  as  I  know,  attention 
has  not  previously  been  drawn.  It  is  all  the  more  deserving  of 
attention  as  the  patient  is  an  eminent  member  of  the  medical 
profession  who  has  watched  and  recorded  his  symptoms  with 
great  care  and  minuteness,  and  as  different  opinions  of  his  case 
have  been  expressed  by  the  distinguished  physicians  whom  he 
has  consulted.  Some  of  these  opinions  are  worth  mentionin^^-. 
One  physician  with  much  experience  in  Indian  diseases  ascribed 
the  symptoms  to  chronic  inflammation  of  the  csccum  and 
ascending  colon ;  but  this  view  aj^peared  to  be  negatived  by 
the  absence  of  inflammatoiy  matters  from  the  stools,  by  the 
persistence  of  the  soreness  for  years  after  all  purging  had  ceased, 
and  by  its  not  accomitiug  for  the  origin  of  the  symptoms  in  an 


512  GALL-STONES:  lect.  xiii. 

inflammatory  attack   during   the  passage  of  gall-stones.     Sir 
Thomas  Watson,  who  was  consulted  in  1867,  looked  upon  the 
soreness  as  a  neuralgic  residue  of  the  gall-stone  attacks.     Now, 
I  have  already  had  occasion  to  mention  to  you  that  neuralgia 
is  an  occasional  sequel  of  biliary  colic  (p.  338)  ;  but  here  the  pain, 
if  indeed  I  may  call  it  so  (for  the  patient  said  it  was  not  j)ain), 
has  not  been  neuralgic  in  its   character;  there  has  been  no 
spinal  tenderness  ;  while  neuralgia  would  not  account  for  the 
diari'hcea  and  for  the  relief  of  the  soreness  whenever  the  patient 
assumes  the  recumbent   posture.     Sir  William  Jenner,  while 
declining  to   express  any  positive   opinion,   thought   that  the 
symptoms  might  be  accounted  for  by  the  presence  of  adhesions 
between  the  gall-bladder  and  surrounding  parts,  and  there  is 
much  in  this  view  to  commend  itself.     It   accounts  for  the 
mode  of  origin  of  the  soreness  and  for  the  influence  of  posture, 
but  it  fails  to  give  a  solution  of  the  diarrhoea  which  immediately 
followed,  and  was  moi-e  or  less  persistent  for  nearly  four  years 
after,  the  inflammatory  attack.     The  view  which  appears  to  me 
to  ofi^er  the  best  explanation  of  all  the  circumstances  of  the 
case   is,  that  in  the  inflammatory  attack  which  occurred   in 
May  18GG,  not  only  did  the  gall-bladder  become  adherent,  but 
a  fistulous  passage  was  established  between  it  and  the  colon, 
such  as  was  present  in  Case  CLXVIII.     The  passage  of  fresh 
bile  into  the  colon  from  the  gall-bladder  would  be  more  likely 
to  occur  when  the  patient  was  erect,  and  might  account  for  the 
feelino"  of  soreness  along  the  ascending  colon  and  also  for  the 
diarrhoea.     It  might  be  contended  in  opposition  to  this  view 
that  no  large  gall-stone  was  found  in  the  stools  after  the  inflam- 
matory attack  in  1866  ;  but  such  a  stone  might  have  been  over- 
looked, and  there  is  no  proof  of  the  necessity  of  a  gall-stone 
being  large  in  order  that  it  should  ulcerate  its  way  from  the 
gall-bladder  into  the  bowel.     In  reference  to  the  view  which  I 
have  suggested  it  is  also  to  be  noted,  that  the  last  attack  of 
biliary  colic  in  June  1866,  about  the  most  severe  and  protracted 
which  the  patient  had  experienced,  was  not  followed  by  a  trace 
of  jaundice.     This  is  just  what  might  have  been  expected  if  the 
stone  had  found  its  way  into  the  bowel  through   the   newly 
formed  fistulous  passage.     Lastly,  the  rarity  of  the  patient's 
symptoms  as  a  sequel  of  biliary  colic  is  in  accordance  with  the 
pathological  fact  already  referred  to  (p.  498),  that  the  fistulse 
between  the  gall-bladder  and  bowel  resulting  from  gall-stones 
almost  invariably  take  the  direction  of  the  duodenum  and  not 


LECT.  XIII.  THEIR    CONSEQUENCES    AND    SYMPTOMS.  513 

of  tlie  colon.  This  very  circumstance,  however,  renders  it  im- 
possible to  make  a  positive  diagnosis. 

Case  CLXIX. — Repeated  Attacks  nf  Biliary  Golic  followed  hj  persis- 
tent Pain  in  right  side  and  Diarrhoea — Fistula  between  Gall-bladder 
and  Colon? 

Dr.    H ,    aged    57,    consulted    me   on   two    occasions    during 

September  1869.  Upwards  of  tbree  years  before  he  had  suffered 
during  three  months  from  a  succession  of  attacks  of  bihary  cohc. 
From  March  12  to  June  15,  1866,  he  had  in  all  19  attacks,  lasting 
134  hom^s,  and  8  or  10  stones  were  found  in  stools.  The  attacks  were 
attended  by  vomiting  ;  but  so  far  as  he  could  remember,  although  on 
this  point  he  was  not  absolutely  certain,  decided  jaundice  first  appeared 
on  May  13,  after  seventeenth  attack  of  colic,  and  subsided  in  a  few 
days.  Several  gall-stones  had  been  found  in  stools  prior  to  May  13; 
a  large  one  was  found  on  May  15,  and  another  on  May  19,  two  days 
after  the  eighteenth  attack  of  colic.  On  May  20  he  had  a  severe  rigor, 
which  lasted  an  hour  and  was  followed  by  fever,  considerable  tender- 
ness over  liver  and  abdomen  generally,  vomiting,  and  diarrhoea.  This 
attack  confined  him  to  bed  for  a  week.  The  last  attack  of  biliary 
colic  occurred  on  June  14  and  15,  and  was  one  of  the  longest  and 
most  severe.  There  was  no  jaundice  with  this  attack,  but  after  it 
was  over  a  small  gall-stone  was  found  in  the  stools.  In  all,  8  or  10 
stones  were  found.  After  these  attacks  of  biliary  colic  he  remained 
very  prostrate  for  several  months,  and  although  then  he  gradually 
regained  strength,  he  had  suffered  ever  since  from  weakness,  sleepless- 
ness, depression  of  spirits,  gastrodynia  and  other  dyspeptic  symptoms, 
but  particularly  from  diarrhoea,  and  from  '  a  feeling  of  soreness  and 
distress,  not  pain,'  in  region  of  ceecum  and  ascending  colon.  This 
soreness  became  permanent ;  it  was  never  absent,  except  when  patient 
was  in  bed  or  in  I'ecumbent  posture ;  and  it  was  so  wearing  and  ex- 
hausting that  he  lost  all  vigour,  and  for  months  at  a  time  he  was 
obliged  to  give  up  all  work.  The  patient  himself  had  always  asso- 
ciated this  soreness  and  the  diarrhoea  with  the  attack  of  diarrhoea 
followed  by  fever  and  abdominal  tenderness,  which  he  had  experienced 
on  May  20,  1866. 

On  careful  examination  of  abdomen,  I  could  discover  nothino- 
abnormal.  I  had  no  opportunity  of  seeing  the  stools  ;  they  were  loose 
and  did  not  exceed  three  or  four  in  the  day.  I  saw  several  of  the 
gall-stones  which  had  been  passed  in  1S66  ;  they  were  about  size  of 
large  peas,  nodulated  on  surface  but  without  facets,  and  composed  of 
pure  cholesterin. 

The  patient  continued  without  any  improvement  until  March  1870, 
when  he  commenced  the  use  of  opium.  He  took  two  or  three  grains 
of  opium  per  diem  by  mouth,  and  as  the  dose  was  gradually  increased 
he  substituted  morphia,  but  he  never  exceeded  three  grains  in  the 

L  L 


514 


GALL-STONES  :  lect.  xiii. 


24  hours.  This  treatment  was  at  once  attended  by  manifest  advan- 
tage. The  side-ache  was  mitigated,  though  not  removed ;  the 
diarrhoea  permanently  ceased  ;  he  felt  fit  for  anything  and  was  in 
every  way  a  changed  man.  In  November  1872  he  substituted  the 
hvpodermic  injection  of  morphia,  which  he  has  persisted  with  ever 
since,  having  injected  4  gr.  daily  during  the  last  two  years.  This 
plan  has  answered  even  better.  Its  invigorating  effects  have  been 
most  remarkable  ;  and  it  has  seemed  to  reach  and  control  the  side- 
ache  in  a  way  that  morphia  by  the  mouth  never  did,  so  that  the 
patient  is  able  (August  1876)  to  perform  a  fair  amount  of  active  duty. 
^Nevertheless,  when  not  under  the  influence  of  morphia,  the  side-ache 
appears  to  have  gained  in  intensity,  and  were  it  not  for  the  morphia 
would  be  quite  unbearable. 

The  following  case  was  of  great  interest  from  several  points 
of  view.  It  was  a  good  illustration  of  tlie  large  size  which  the 
gall-bladder  sometimes  attains  from  the  effects  of  inflammation, 
and  it  showed  how  readily  this  condition  may  be  mistaken  for 
abscess  of  the  liver.  Before  the  passage  of  the  renal  calculus, 
the  previous  history  of  the  patient  and  the  fact  that  the  sym- 
ptoms were  evidently  connected  with  the  right  kidney  suggested 
the  idea  that  a  biliary  calculus  might  have  ulcerated  its  way 
into  the  pelvis  of  the  right  kidney  and  obstructed  the  right 
ureter,  as  in  the  cases  I  have  already  brought  under  your  no- 
tice (p.  500),  but  the  analysis  of  the  stone  left  no  doubt  that  the 
patient  was  the  subject  of  both  renal  and  biliary  calculi.  The 
concurrence  of  these  two  maladies  was  long  ago  pointed  out  by 
Baglivi  and  Morgagni,'  and  has  recently  been  made  the  subject 
of  fresh  investigations  by  Dr.  Senac  of  Yichy,  who  found  that 
out  of  128  patients  suffering  from  hepatic  colic,  98  were  either 
simultaneously,  or  had  been  previously,  the  subjects  of  lithic 
acid  gravel.^ 

Case  CLXX. — Hepatic  Colic— Closure  of  Cystic  Duct — Abscess  of  Gall- 
Madder — Discharge  of  Gall-stones  through  a  fistulous  Ojjeuing  in 
Abdominal  Parietes — Passage  of  Renal  Calculus. 

On  June  18,  1867,  the  Countess ,  about  54  years  of  age,  con- 
sulted mc  on  account  of  a  fistulous  opening  in  abdominal  parietes,  and 
gave  following  history  of  her  illness,  which  was  subsequently  supple- 
mented by  Mr.  Bickersteth  of  Liverpool,  who  had  previously  attended 
her.  In  previous  autumn  she  had  suffered  from  an  attack  of  biliary  colic 
with  jaundice  and  vomiting,  which  had  passed  off  after  two  or  three 
weeks.  Towards  end  of  year  she  had  been  attacked  with  persistent  pain 

>  Du  sedibus  ct  causis  morboruui,  Kpist.  xxxvii.  "  Op.  cit.  p.  9-i. 


LECT.  xm.  THEIR   CONSEQUENCES    AND    SYMPTOMS.  5 1 5 

in  reg'ion  of  liver,  wliicli  gradually  increased  and  was  attended  by  con- 
siderable fever  and  otber  symptoms  of  constitutional  disturbance,  but 
not  by  jaundice.  Very  soon  an  enlargement  was  noticed  in  right  bypo- 
cbondriura,  and  early  in  February  there  were  all  the  signs  of  a  deep- 
seated  abscess  below  right  ribs,  while  patient's  general  condition  was 
such  as  to  excite  considerable  alarm.  Abscess  was  opened  by  Mr. 
Bickersteth  with  potassa  fasa,  integuments  having  been  previously 
divided.  Nearly  a  pint  of  '  tolerably  healthy  pus  not  mixed  with  bile 
escaped  after  a  few  days.'  All  hepatic  symptoms  ceased  and  she 
slowly  recovered  strength.  Some  weeks  afterwards,  another  small 
superficial  abscess  was  opened  at  umbilicus.  The  second  opening  soon 
closed,  but  first  continued  to  discharge  small  quantities  of  pus  and  of 
a  glairy  fluid,  and  sometimes  a  little  blood.  This  opening  was  situated 
about  two  inches  above  and  to  right  of  umbilicus,  and  at  about  an 
equal  distance  from  natural  situation  of  fundus  of  gall-bladder.  It 
had  a  diameter  of  about  2  lines,  was  slightly  depressed  below  surface, 
and  was  surrounded  on  all  sides  for  about  2  in.  by  considerable 
induration  of  abdominal  parietes,  which,  in  an  upward  direction, 
amounted  almost  to  a  stony  hardness.  On  introducing  a  probe 
the  fistula  seemed  to  take  an  upward  direction,  but  as  instrument 
caused  pain  and  slight  bleeding  it  could  not  be  carried  farther  in  than 
half  an  inch.  Patient  complained  of  dragging  pains  round  opening 
and  in  right  hypochondrium,  and  of  occasional  attacks  of  nausea  and 
headache,  but  there  were  no  other  indications  of  constitutional  dis- 
turbance. From  the  history  I  expressed  the  opinion  at  ray  first 
visit  that  abscess  had  not  been  in  liver,  but  in  gall-bladder,  and  I 
ventured  to  predict  that  sooner  or  later  this  would  be  proved  by  dis- 
charge of  gall-stones  through  fistulous  opening.  Poultices  were  kept 
constantly  applied  over  opening,  and  quinine  with  nitric  acid,  and 
occasionally  purgatives,  were  ordered  to  be  taken  internally. 

On  July  28  first  gall-stone  came  away  through  opening.  It  was 
about  siz3  of  a  pea  and  presented  several  facets.  Its  passage  through 
fistula  was  attended  for  several  days  by  considerable  pain,  and  its 
escape  was  followed  by  discharge  of  a  good  deal  of  thick  yellow  nus. 
On  Aug.  16  three  more  concretions  came  away,  one  somewhat  larger 
than  first,  two  others  very  small.  There  was  again  for  some  hours 
a  good  deal  of  pain,  and  after  exit  of  calculi  a  discharge  of  thick  matter 
w'ith  a  small  quantity  of  blood.  In  September  and  October  two  or 
three  more  concretions  escaped,  and  on  Dec.  19,  after  two  days  and 
nights  of  intense  pain,  a  polygonal  calculus  found  its  way  out,  which 
was  fully  half  an  inch  in  diameter.  Another  smaller  concretion  (ninth) 
escaped  in  Jan.  18ti8. 

After  this,  induration  surrounding  opening  greatly  diminished, 
but  there  was  still  a  mass  of  stony  hardness,  about  size  of  a  walnut, 
immediately  above  it.  Opening  was  not  more  than  a  line  in  diameter 
and  was  retracted  to  bottom  of  a  deep  depression  with  puckering  and 

LL  2 


5l6  GALL-STONES:  lect.  xiii. 

induration  of  surrounding  skin.  This  change  was  mainly  due  to 
greater  thickness  of  abdominal  wall  from  deposit  of  fat.  Several 
times  after  escape  of  ninth  stone,  and  in  intervals  of  escape  of  previous 
ones,  opening  showed  a  tendency  to  close  and  caustic  was  applied. 
On  one  occasion  an  attempt  was  made  to  dilate  fistula  by  a  tent  of 
sea-tangle,  but  removal  of  the  swollen  tent  from  tortuous  tract  caused 
so  much  pain  that  procedure  was  abandoned.  Patient  gained  flesh 
and  strength,  looked  extremely  well,  had  a  good  appetite  and  digestion, 
and  only  suffered  from  inconvenience  of  discharge  from  fistulous 
opening. 

Eai'ly  in  June  1868,  another  stone,  tenth  and  last,  came  away. 

Opening  continued  to  discharge  thin  pus,  and  it  did  not  finally  close 

till  August  1869,  but  since  then  it  has  shown  no  sign  of  reopening, 

and  there  lias  been  no  pain  nor  induration  in  vicinity  of  cicatrix  (1876), 

On  Sept.  27,  1868,  more  than  three  months  after  passage  of  last 

stone,  and  while  fistulous  opening  was  still  discharging,  patient  was 

again  siiddenly  seized  with  rigors,  vomiting  and  fever,  but  this  time 

associated    with    urinary    symptoms — frequent    micturition,    intense 

burning  pain  in   meatus  urinarius,   and   presence   of  blood  in  small 

quantity,  and  subsequently  of  pus,  in  urine.     These  symptoms  subsided 

after  about  a  fortnight,  but  on   Nov.    8    pain,    vomiting,    and   fever 

returned    in   an    aggravated   form,    and    a   very    tender    deep-seated 

swelling,  about  size  of  a  small  orange,  could  be  felt  in  right  groin 

]:alf-way  between  crest  of  ilium  and  pubes.     Urine  was  now  perfectly 

limpid  and  free  from  pus  or  blood.     Sir  Henry  Thompson,  who  saw 

patient  with  me  in  consultation,  agreed  in  thinking  that  swelling  was 

connected  with  right  ureter.     After  a  few  days  pus  returned  to  urine, 

which   also    contained   many  crystals    of  lithic   acid,   but   no  stone. 

Tumour  in  right  groin  could  still  be  felt  on  IS^ov.  30,  but  it  was  much. 

smaller,   and  it   soon   entirely  disappeared,  and  patient  regained  her 

usual  health,  urine,  however,  still  containing  a  little  pus.     In  August 

1869,  about  time  that  fistula  in  abdominal  parietes  closed,  pus  dis- 
appeared from  urine. 

From   this  time   patient  remained  in  good  health   until  Sept,   7, 

1870,  when  she  was  again  suddenly  seized  with  rigors,  vomiting, 
violent  paroxysmal  pain  in  region  of  right  kidney  stretching  round 
to  cicatrix  and  to  riyht  hip,  much  fever  and  frequent  micturition, 
but  urine  contained  no  blood  nor  pus,  and  there  was  no  induration  nor 
swelling  in  neighbourhood  of  cicatrix.  These  symptoms  continued  in 
a  more  or  less  severe  form  till  Sept.  26,  when  suddenly  several  ounces 
of  pure  pus  were  discharged  with  urine,  and  on  following  morning  a 
calculus  was  passed  from  urethra.  All  severe  symptoms  at  once 
subsided,  and  although  urine  for  some  weeks  contained  a  good  deal  of 
pus,  this  at  last  disappeared  and  patient  has  till  now  (1876)  enjoyed 
good  health,  except  tliat  she  has  suffered  occasionally  from  aching  and 
<li-agging  pains  in  region  of  liver  and  right  kidney. 


LFCT.  xm.  THEIE    CONSEQUENCES    AND    SYMPTOMS.  517 

Dimensions  of  stone  were  as  follows  : — Length  |  inch,  width 
^  inch,  thickness,  -<j%  in.  Its  weight  was  3  gr.  It  was  analysed 
by  Mr.  Thomas  Taylor,  who  found  it  to  be  composed  of  uric  acid. 

The  following  case  occurred  while  I  was  patholog-ist  to 
Middlesex  Hospital,  and  was  recorded  by  me  in  the  Patho- 
logical Transactions  (vol.  xii.  p.  85).  The  sequence  of  events 
was  probably  as  follows  : — 

1.  Ulceration  of  the  interior  of  the  gall-bladder  from  the 
presence  of  a  gall-stone,  perforation  of  its  coats,  and  the  for- 
mation of  fistulous  communications  with  the  duodenum  and 
colon,  by  which  the  calculus  escaped  into  the  bowel,  as  in  the 
specimen  in  St.  Bartholomew's  Hospital  Museum  already 
referred  to  (p.  499). 

2.  Rupture  by  straining  of  some  of  the  adhesions  between 
the  bowels,  and  the  formation  of  a  circumscribed  faecal  abscess 
which  opened  externally. 

3.  Blood-poisoning,  pysemic  abscesses,  lobular  pneumonia, 
and  pericarditis. 

Case  CLXXI. — Fistula  in  Abdominal  Parietes  opening  into  a  circum- 
scribed Cavity  whicJi  com,muniGated  tvith  Colon  and  Dioodenum,  and 
indirectly  with  Gall-bladder. 

B.   Z ,  aged   38,   was   admitted   into    Middlesex    Hospital   on 

Sept.  25,  1860,  and  died  on  'Noy.  14.     Married  twice  ;  eight  children 
and  six  miscarriages. 

About  a  year  before  death,  without  any  apparent  cause,  she  was 
suddenly  seized  with  sickness,  vomiting,  and  great  prostration,  which 
symptoms  were  followed  by  general  fever  and  tenderness  over  abdo- 
men. Bowels  were  regular.  After  a  few  weeks  she  recovered,  and 
remained  in  her  ordinary  health  u.p  to  Sept.  14,  1860. 

On  Sept.  13  she  fancied  that  she  strained  abdominal  muscles  by 
carrying  some  heavy  pails  of  water  upstairs.  On  following  morning 
she  awoke  with  slight  pain  in  abdomen,  which  was  greatly  increased 
after  breakfast,  and  was  then  accompanied  by  sickness  and  vomiting 
of  a  green  bitter  fluid.  She  said  pain  was  just  as  if  her  abdomen  had 
been  tied  round  with  a  rope.  Sickness  abated  after  three  days,  when 
bowels  had  been  freely  opened  by  medicine,  but  pain  continued  and 
patient  became  very  weak.  On  admission  into  hospital,  great  tender- 
ness of  abdomen,  which  was  most  intense  at  umbilicus.  Immediately 
to  left  of  umbilicus  was  a  superficial  circular  swelling  with  a  firm 
dense  rim  and  doughy  in  centre.  Motions  of  bowels  normal.  Pulse 
144.     Great  prostration. 

ISText  day  (26th)  a  little  yellow  pus  of  a  stercoraceous  odour,  but 
exhibiting  nothing  except  pus-cells  under  ruicroscope,  could  be  squeezed 


5l8  GALL-STOIS'ES 


XECT.    XTII. 


tlirougli  umbilicus.  After  this  date  opening  continued  to  discharge 
large  quantities  of  fetid  pus.  From  Sept.  30  to  Oct.  17,  pus  was 
mixed  with  fsecal  matter.  On  IS'ov.  9  opening  ceased  to  discharge 
even  pus. 

About  three  weeks  before  death  abscesses  began  to  form  in  various 
parts  of  body,  over  right  parotid,  in  soft  parts  of  right  hip,  &c.,  and 
patient  suffered  from  great  dyspncBa  and  expectorated  purulent  sputa. 
It  was  impossible  to  examine  chest,  as  slightest  movement  or  manipu- 
lation caused  great  pain.  The  prosti'ation  gradually  increased,  and 
death  took  place  on  Nov.  14. 

Autopsy. — Body  greatly  emaciated.  An  abscess  containing  seven 
or  eight  ounces  of  pus  in  right  hip.  At  umbilicus  was  a  fistulous 
opening  large  enough  to  admit  a  goose-quill.  This  opened  into  a 
sloughy  cavity,  size  of  a  small  orange,  which  communicated  with 
transverse  colon  and  duodenum,  and  indirectly  with  gall-bladder. 
Opening  into  colon  was  large  enough  to  admit  finger ;  colon  at  this 
place  was  much  constricted,  and  its  lining  membrane  injected  and 
slightly  ulcerated.  Immediately  to  right  of  this  opening  gall-bladder 
was  firmly  adherent  to  colon.  Gall-bladder  small  and  contained  about 
two  drachms  of  whey-like  fluid,  without  any  tint  of  bile ;  cystic  duct 
obliterated,  but  no  gall-stones.  Between  fundus  of  gall-bladder  and 
colon  was  a  fistulous  communication  running  somewhat  obliquely, 
and  just  large  enough  to  admit  a  No.  1  catheter;  inner  surface  of  gall- 
bladder around  this  opening  marked  by  an  extensive  radiated  cicatrix. 
The  fistula  between  sloughy  ca,vity  and  duodenum  was  large  enough 
to  admit  a  crow-quill,  and  opened  into  duodenum  immediately  beyond 
pylorus.  Abdominal  parietes  around  sloughy  cavity  were  inseparably 
adherent  to  viscera  ;  no  fluid  in  peritoneum.  About  one  pint  of  clear 
serous  fluid  in  left  pleural  cavity.  A  few  old  adhesions  over  apex  of 
left  lung,  which  for  most  part  was  normal,  but  lower  lobe  contained 
several  nodules  of  lobular  pneumonia,  largest  about  size  of  a  walnut, 
gre}'',  granular,  bulging  above  surface  on  section  and  very  friable. 
Two  or  three  pints  of  turbid  serous  fluid  containing  numerous  flakes 
of  lymph  in  right  pleural  cavity,  and  lung  glued  to  walls  of  chest  an- 
teriorly and  at  apex  by  recent  lymph.  Lower  lobe  of  right  lung  col- 
lapsed, non-crepitant,  sinking  in  water,  smooth  on  section,  and  very 
tenacious. 

Fully  eight  fluid  ounces  of  a  gelatinous,  yellowish,  opaque,  puriform 
substance  in  pericardium,  which  could  be  scooped  out  in  one  .semi-solid 
mass.  This  substance,  on  microscopic  examination,  was  found  to  con- 
sist of  fine  fibrillated  material  with  numerous  lymph  or  pyoid  corpuscles, 
but  no  true  pus-cells  with  characteristic  nuclei.  Pericardium  insepa- 
rably adherent  to  left  ventricle  over  a  space  measuring  1^  in.  in 
diameter.  Outer  surface  of  heart  covered  with  membranous  patches 
of  lymph,  many  of  which  were  firmly  adherent. 


x,ECT.  XIII.  THEIE   CONSEQUENCES   AND    SYMPTOMS.  519 

Case  CLXXIl. — Biliary  Fistula,  in  Ahdominal  Parietes  discharging  hile. 

On  Oct.  11,  1869,  I  saw  with  Mr.  Cui-ling  a  married  lady,  about  40 
years  of  age,  who  had  a  biliary  fistula.  For  many  years  she  had  been 
liable  to  sudden  paroxysms  of  severe  pain  in  right  hypochondrium, 
accompanied  by  vomiting  but  never  followed  by  jaundice.  In  March 
1869  she  first  noticed  a  painful  swelling  in  abdomen,  below  right  ribs 
in  front.  Different  opinions  respecting  this  swelling  had  been  ex- 
pressed by  different  medical  men  who  had  been  consulted.  One  was 
that  it  was  a  fibrous  tumour,  and  another  that  it  was  a  hydatid.  The 
swelling  increased,  and  as  fluctuation  became  more  distinct  an  opening 
was  made  into  it  in  May,  and  many  ounces  of  viscid,  opaque,  yellow 
fluid,  without  any  trace  of  bile,  came  away.  On  June  3  a  biliary  con- 
cretion, not  larger  than  a  hemp-seed,  was  discharged  through  opening, 
and  early  in  September  four  others,  somewhat  larger  and  with  distinct 
facets,  came  away.  On  Sept.  18  she  began  to  sufier  from  much  pain 
about  liver  in  front  and  stretching  round  to  back,  and  after  two  or 
three  days  two  other  small  concretions  were  passed  and  the  pain  was 
relieved.  One  week  after  this  she  awoke  in  night  with  agonising  pain 
in  right  hypochondrium  and  back  and  violent  retching.  After  a  few 
hours  these  symptoms  subsided,  but  two  nights  later  (Sept.  27)  they 
returned,  and  next  morning  she  found  her  night-dress  and  the  bedding 
saturated  with  bile.  From  that  time  until  I  saw  her,  fourteen  days 
afterwards,  there  had  been  a  steady  discharge  of  dark'  green  bile  from 
the  fistulous  opening,  which  was  situated  half-way  between  umbilicus 
and  lower  edge  of  ribs  in  right  nipple  line.  The  fluid  was  discharged 
from  opening  at  rate  of  from  1  to  2  oz.  in  hour,  sometimes  more  and 
sometimes  less.  It  was  usually  increased  after  a  meal.  Ithadallthe 
characters  of  pure  dark  green  bile.  The  patient  was  losing  flesh  and 
strength  rather  rapidly,  and  suff'ered  much  from  pain  and  flatulence 
after  meals.  Urine  was  dark  and  contained  bile-pigment,  and  motions 
were  clay-coloured,  with  no  vestige  of  bile,  but  there  was  scarcely  any 
jaundice  of  skin  or  conjunctivae.  Three  days  after  I  saw  the  patient 
(Oct.  14)  another  small  biliary  concretion  Avas  discharged  from  opening  ; 
but  there  was  no  improvement  in  general  symptoms,  and  patient  con. 
tinued  getting  weaker  until  about  Nov.  7,  when  she  had  another  attack 
of  severe  pain  in  right  side  and  vomiting,  and  next  day  she  found  that 
discharge  from  fistulous  opening  had  almost  stopped  and  that  there  was 
plenty  of  bile  in  motions.  The  patient's  general  health  gradually  im- 
proved, and  within  a  few  weeks  she  was  able  to  sail  for  the  West 
Indies,  but  in  Dec.  1872  there  was  still  a  minute  fistulous  opening 
below  the  right  ribs  discharging  glairy  mucus. 

The  several  stages  of  this  remarkable  case  appear  to  have 
been  as  follows : 

1.  A   concretion,    which   had  formed  in  the    gall-bladder, 


520  GALL- STONES  :  lect.  xm. 

entered  tlie  cystic  duet,  causing  paroxysms  of  hepatic  pain  and 
vomiting.  It  did  not  reach  the  common  duct,  and  therefore 
there  was  no  jaundice. 

2.  The  cystic  duct  being  closed,  no  bile  could  enter  the 
gall-bladder ;  the  bile  already  there  was  absorbed ;  the  gall- 
bladder took  on  inflammation,  and  became  distended  with  an 
opaque  viscid  fluid,  forming  a  tumour  which  was  appreciable 
through  the  abdominal  parietes. 

3.  An  opening  was  made  into  this  cyst,  and  its  contents 
evacuated.  A  fistulous  opening  remained,  which  discharged 
viscid  fluid  and  gave  exit  to  several  small  gall-stones. 

4.  With  a  fresh  attack  of  biliary  colic  and  vomiting  the 
concretion  in  the  cystic  duct  was  dislodged  and  passed  into  the 
common  duct,  which  it  obstructed.  The  result  was  that  the 
bile  was  prevented  entering  the  bowel,  and,  passing  along  into 
the  gall-bladder,  escaped  by  the  fistulous  opening,  and  thus  no 
jaundice  resulted. 

5.  With  another  attack  of  biliary  colic  and  vomiting  the 
concretion  escaped  into  the  duodenum,  the  flow  of  bile  was  re- 
stored to  its  proper  channel,  and  the  fistulous  opening  closed. 

This  appears  to  be  the  only  possible  explanation  of  the  facts 
of  the  case,  but  on  this  view  it  is  extraordinary  that  a  concre- 
tion which  had  blocked  the  cystic  duct  for  many  months  should 
ultimately  have  been  dislodged  and  passed  into  the  common 
duct ;  and  that  the  common  duct  should  have  become  pervious 
after  complete  obstruction  by  a  gall-stone  for  nearly  six  weeks 
was  also  almost  more  than,  under  the  circumstances,  there  was 
reason  to  expect.  The  quantity  of  bile  secreted  by  the  liver 
in  this  case  could  not  have  been  much  under  two  pints  in 
the  twenty-four  hours,  and  this  though  the  patient  was  taking 
very  little  food. 

I  only  saw  her  on  one  occasion,  and  she  was  much  too  ill  to 
warrant  any  experiments  with  regard  to  the  action  of  drugs  on 
the  secretion  of  bile. 

Case  CLXXIII.  is  another  example  of  external  biliary  fistula 
produced  by  gall-stones.  In  addition  to  the  three  cases  which 
I  have  now  brought  under  your  notice,  I  have  met  with  two 
others,  one  in  a  lady  aged  82,  who  never  had  jaundice  ;  and  a 
second  in  a  lady  upwards  of  70,  who  had  had  two  attacks  of 
hepatic  colic  with  jaundice,  ten  and  five  jenrs  before. 


LECT.  xiii.  THEIR   CONSEQUENCES    AND    SYMPTOMS.  $21 

Case  CLXXIII. — Numerous  Gall-stones  discharged  hyfistalous  Openings 

at  Uinhilicus. 

Mrs.  G ,  58,  consulted  me  on  April  4,  18/2,  by  advice  of  Mr. 

J.  C.  Lynch  of  Sudbury.  About  three  months  before,  she  had  been 
seized  with  vomiting  and  severe  pain  in  region  of  liver.  Very  soon  a 
hard  painful  swelling,  about  size  of  a  hen's  egg,  appeared  between 
right  ribs  and  umbilicus,  which  after  four  or  five  weeks  opened  at 
umbilicus,  discharging  much  pus,  but  no  bile.  Two  days  after  a  gall- 
stone came  ont,  and  since  then  many  hundreds  had  been  extruded, 
from  size  of  a  hemp-seed  to  that  of  a  very  large  pea.  She  brought 
328  with  her  in  a  parcel.  I'he  larger  stones  had  caused  much  pain 
in  passing.  At  time  of  her  visit  to  me,  patient  had  three  fistulous 
openings  surrounded  by  pouting  red  flesh  and  discharging  a  viscid 
fluid,  just  to  right  of  umbilicus,  and  a  stone  had  come  away  night 
before.  For  years  she  had  suffered  from  'bilious  headaches,'  but 
before  this  attack  she  never  had  pain  in  right  side,  and  at  no  time 
jaundice. 

Juhj  25,  1876. — During  the  five  months  which  followed  Mrs.  G.'s 
visit  to  me,  27  more  gall-stones  were  passed.  After  this  the  fistula 
closed,  and  since  then  Mrs.  G.  has  enjoyed  better  health  than  she 
had  done  for  many  years  previously. 

In  the  following  case,  althougli  the  patient  had  cancer  of 
the  liver,  the  chief  pathological  interest  v^as  the  fact  of  a 
gall-stone  having  found  its  way  into  the  interior  of  the  portal 
vein. 

Case  CLXXIV. — Cancer  of  Liver — Ulceration  of  Gall-stone  into  Portal 
Vein — Phlehitis — Pyoitnia — Peritonitis  from  rupture  of  hepatic  ahscess 
— Recent  Endocarditis. 

Hannah  L ■,  aged   57,  adra.  into  St.    Thomas's   Hosp.  Feb.  7, 

1876.  Father  died  at  45  of  consumption ;  mother  lived  to  70  ;  had 
8  brothers  and  7  sisters  ;  none  of  them  alive ;  all  3  brothers  died 
of  consumption.  No  history  of  gout,  rheumatism,  or  syphilis. 
Throughout  life  had  enjoyed  good  health,  except  that  she  had  often 
suffered  from  severe  spasms  in  abdomen  after  menstruation  ;  catamenia 
had  ceased  at  40,  but  she  had  continued  to  suffer  from  severe  darting 
pains  in  abdomen  without  vomiting  or  jaundice.  Two  years  before 
admission  into  hospital  she  began  to  get  weak  and  thin,  and  for  eight 
months  she  had  been  subject  to  epigastric  pain  and  had  occasionally 
vomited  her  food.  Still  she  continued  to  go  about  and  earn  her  living 
as  a  laundress.  Six  weeks  before  admission,  while  washing,  she  was 
suddenly  seized  with  severe  pain  in  right  little  toe,  which  soon  became 
swollen,  red,  and  tender.  In  consequence  of  this  she  was  obliged  to 
give  up  work  and  kept  her  bed  half  the  day. 


522  GALL-STONES  :  lect.  xiii. 

On  admission,  patient  was  emaciated  and  had  moderate  jaundice 
of  ^kin  and  conjunctivse ;  there  was  gangrene,  not  spreading,  of  right 
little  toe,  with  swelling,  lividity,  and  some  tenderness  along  outer  side 
of  right  foot.  But  chief  complaint  was  of  pain  in  upper  part  of 
abdomen  and  back,  constant,  yet  subject  to  severe  exacerbations, 
persistent  nausea  and  occasional  retching.  Tongue  coated  and  dry 
down  centre  ;  bowels  costive.  No  ascites.  Liver  apparently  much 
enlarged,  extending  from  level  of  nipple  to  below  umbilicus  ;  enlarge- 
ment uniform ;  surface  hard,  uneven,  and  extremely  tender.  Pulse 
96,  weak ;  heart-sounds  feeble  ;  no  bellows-murmur.  No  cough ; 
lungs  healthy.     Temp.  101*2°.     Urine  1015  ;  no  albumen. 

After  admission  temperature  soon  fell  to  normal  standard,  but 
patient  became  rapidly  weaker  and  died  on  Feb.  13. 

Autopsy. — Liver  attached  by  thick  adhesions  consisting  in  part  of 
new  growth  to  anterior  abdominal  wall  and  surrounding  organs,  in 
such  a  manner  as  to  divide  peritoneal  cavity  into  two  portions.     Upper 
space  contained  a  quantity  of  dirty  greenish-yellow  fluid,  resembling 
bile  mixed  with  pus.  Upper  surface  of  liver,  which  formed  part  of  wall 
of  this  space,  presented  all  the  signs  of  recent  acute  inflammation  and 
also  two  irregular  softened  patches  with  perforation,  from  which  fluid 
exuded  similar  to  that  in  cavity  above.     Anterior  border  of  liver  also 
adherent  to   pyloric   extremity  of  stomach  and  to   pancreas,  a  large 
irregular    nodulated   mass   of    cancer  infiltrating  and  uniting  them. 
This  mass  occupied  situation  of  gall-bladder,  and  extended  into  portal 
fissure  and  adjoining  portion  of  liver.     Portal  vein  and  common  bile- 
duct  passed  into  it ;  latter  contained  bile,  and  did  not  appear  to  be 
much    obstructed.      Portal    vein,   at    about  one  inch  from    where  it 
entered  mass,  opposite  hilus  of  liver,  was  expanded  into  an  irregular 
cavity  with  dark,  ulcerated,  sloughy  walls,  which  contained  an  oblong 
gall-stone,  measuring  half  an  inch  in  longest  diameter.     No  outlet  to 
the  cavity  other  than  the  branches  of  vein  could  be  discovered.     From 
this  point  branches  of  portal  vein  were  intensely  inflamed,  and  filled 
for  some  distance   with   adherent  clot   partially  softened  in  centre  ; 
several  of  terminal  branches  also  filled  with  adherent  partially  de- 
colorised clot,  and  corresponding  tracts  of  liver-tissue  of  a  dead  white 
or  yellowish  colour,  and  moi"e  or  less  softened,  like  pyasmic  abscesses 
in  an  early  stage,  and  surrounded  by  a  zone  of  injection.      Two  large 
irregular  tracts  of  this  chai-acter  on  upper  surface  of  right  lobe  had 
superimposed   peritoneum    sloughy,    with    several    perforations   from 
which  contents  had  escaped  into  peritoneal  cavity.     There  were  also 
throughout  liver,  especially  in  left  lobe,  several  nodules  of  new  growth 
from  ^-  to  'l  in.  in  diameter,  hard,  and  where  they  approached  surface 
flattened  and  slightly  depressed.     Spleen  7^  oz.,   soft ;    it  contained 
several  recent  infarcti,  partially  softened.     Kidneys  small,  with  recent 
embolisms  and  deep  scai's  from  others  of  old  date.     Numerous  small 
flattened    nodules    of  new  growth   on   under  surface   of  diaphragm. 


LECT.  xnr.  ENLAEGEMENTS    OF    THE    GALL-BLADDEE.  523 

Lungs  free  from  both  infarct!  and  new  growth.  Valves  of  heai^t 
competent ;  but  a  small  recent  vegetation  on.  centre  of  one  of  aortic 
flaps,  and  masses  of  recent  vegetation  on  auricular  surface  of  mitral  valve. 

C.    ENLAEGEMENTS    OP    THE    GALL-BLADDEE. 

In  the  diagnosis  of  diseases  of  the  liver  it  is  important  to 
keep  in  view  the  various  causes  of  enlargement  of  the  gall- 
bladder. Before  closing  this  lecture  I  shall  therefore  say  a  few 
Avords  on  the  distinctive  characters  of  these  enlargements, 
which,  for  clinical  purposes,  may  be  said  to  be  due  to  five 
causes :  viz.  :  I.  Accumulation  of  Bile  ;  II.  Suppuration ;  III. 
Dropsy ;  IV.  Gall-stones  ;  V.  Cancer. 

I.  Enlargement  of  the  Gall-bladder  from  Accumulation  of  Bile. 

Enlargement  of  gall-bladder  from  accumulation  of  bile,  as 
I  have  already  told  you  (pp.  101,341),  is  one  of  the  first  conse- 
quences of  obstruction  of  the  common  duct,  and  it  is  then  dis- 
tinguished by  the  following  characters  :  — 

1.  Jaundice,  which  gradually  becomes  intense. 

2.  Absence  of  bile  from  the  motions. 

3.  General  enlargement  and  tenderness  of  the  liver  (see  p. 
161). 

4.  An  elastic  or  fluctuating  pear-shaped,  somewhat  tender 
tumour,  projecting  from  the  edge  of  the  liver  in  the  situation 
of  the  gaU-bladder.     Dr.  Bright  has  recorded  a  case  where  the 
gall-bladder  in  this  condition  formed  a  fluctuating  tumour  ex- 
tending almost  to  the  crest  of  the  ilium ;  ^  Dr.  Babington  re- 
lates a  case  in  which  the  gall-bladder  contained  three  wash- 
hand  basins  of  bile  ;  ^  and  Copland  mentions  another  in  which 
it  contained  8  pints  of  bile,  and  was  so  large  as  to  protrude  the 
false  ribs  on  both  sides. ^     It  is  not  often,  however,  that  the 
dimensions  of  the  tumour  are  so  great.     The  tumour  may  sud- 
denly subside  with  the  discharge  of  a  large  quantity  of  bile  in 
the  motions  and   the  disappearance    of  the  jaundice.     When 
the  obstruction  of  the  bile-duct  is  pei'manent,  the  bile  in  the 
gall-bladder  is  often  gradually  absorbed  and  after  a  time  a 
condition  of  atrophy  may  be  substituted  for  that  of  dilatation. 
Sometimes   the    distended    gall-bladder,   when    its    coats    are 
softened  by  inflammatory  action    or   fatty   degeneration,  will 
rupture  and  cause  fatal  peritonitis,  as  in  Case  CLXV. 

»  Abdom.  Tumours.  Syd.  Soc.  Ed.  p.  271.        "^  Guy's  Hosp.  Eep.  1842-3,  vol.  vii. 
*  Diet,  of  Pj-nrtical  Med.  vol.  ii.  p.  4. 


524  ENLAEGEMENTS    OF    THE    GALL-BLADDER:  lect.  xiii. 

Rare  cases  have  been  recorded  where  a  gall-stone  in  the 
neck  of  the  gall-bladder,  or  in  the  cystic  duct,  has  acted  like  a 
plug-valve,  permitting  bile  to  enter  the  gall-bladder,  but  pre- 
venting its  exit,  and  where  bile  has  in  consequence  accumulated 
in  the  gall-bladder.  In  such  cases  there  need  be  no  jaundice 
nor  clay-coloured  motions,  but  the  occurrence  is  so  rare  as  not 
often  to  embarrass  the  diagnosis. 

In  former  lectures  I  have  brought  under  your  notice  several 
instances  of  enlargement  of  the  gall-bladder  from  accumulation 
of  bile  (Case  LXVI.  p.  163,  Case  CXXII.  p.  376,  Case  CXXIV. 
p.  379,  and  Case  CXXVII.  p.  383). 

II.  Enlargement  of  the  Gall-Bladder  from  Suppuration. 

The  gall-bladder  occasionally  becomes  distended  with  pus, 
which  may  be  mixed  with  bile,  or  may  be  indistinguishable 
from  that  of  an  ordinary  abscess,  as  in  Case  CLXX.  Inflamma- 
tion of  the  gall-bladder  may  follow  its  over-distension  with  bile 
from  obstruction  of  the  common  duct ;  but  in  most  cases  of 
suppuration  it  is  the  cystic  duct  only  that  is  obstructed,  and 
the  inflammation  is  limited  to  the  gall-bladder,  and  is  due  to 
the  irritation  of  gall-stones,  or  to  some  other  cause.  It  is  then 
characterised  by : — 

1.  A  tumour  corresponding  in  situation  and  shape  to  that 
caused  by  distension  with  bile,  but  more  painful  and  tender, 
and  accompanied  by  more  febrile  disturbance,  and  often  by 
rigors,  pyrexia,  and  night-sweats.  There  are  in  fact  all  the 
characters  of  hepatic  abscess,  from  which  even  its  shape  and 
situation  may  not  suffice  to  distinguish  it. 

2.  There  is  no  jaundice. 

3.  The  motions  contain  bile. 

4.  There  is  no  general  enlargement  nor  tenderness  of  the 
liver. 

5.  Occasionally,  as  in  Case  CLXX.,  there  is  a  previous  his- 
tory of  biliary  colic. 

6.  It  is  only  the  tropical  abscess  of  the  liver  (see  p.  186) 
which  is  simulated  by  suppuration  of  the  gall-bladder,  and  ac- 
cordingly the  diagnosis  may  be  assisted  by  the  circumstance 
of  a  tumour  answering  to  the  description  now  given,  occurring 
in  a  patient  who  has  never  been  in  a  tropical  country. 

Enlargement  of  the  gall-bladder  from  inflammation  very 
often  slowly  disappears  under  treatment;  occasionally  it  opens 
externally  or  into  the  bowel. 


lECT.  XIII.  THEIR    VARIETIES    AND    CHARACTERS.  525 


III.  Enlargement  of  the  Gail-Bladder  from  Dropsy  {Hydrops 
Cystidis  Fellece). 

When  the  gall-bladder  is  distended  with  pus  it  may  open 
externally  and  form  a  biliary  fistula,  or  it  may  burst  into  the 
peritoneum  or  into  the  bowel.  But  occasionally  a  thin  flaky 
liquid  appears  to  be  substituted  for  the  pus  ;  or  sometimes, 
from  the  inflammatory  process  being  slight  and  chronic,  the 
fluid  has  these  characters  from  the  first.  This  is  what  is  meant 
by  dropsy  of  the  gall-bladder.  It  is  not  a  dropsy  in  the  strict 
sense  of  the  word,  but  a  chronic  inflammation.  Enlargement 
of  the  gall-bladder  from  this  cause  has  all  the  characters  of 
enlargement  from  suppuration,  except  that  it  is  scarcely,  if  at 
all,  painful,  and  that  it  is  not  necessarily  accompanied  by  feb- 
rile disturbance.  This  consequently  is  the  form  of  enlarge- 
ment of  the  gall-bladder  which  is  most  readily  mistaken  for  a 
pendulous  hydatid  (see  p.  59),  from  which  it  is  to  be  distin- 
guished mainly  by  its  situation,  and  by  the  fact  of  its  develop- 
ment being  often,  though  not  necessarily,  preceded  by  a  history 
of  biliary  colic.     (See  Case  CLXXII.) 

IV.  Enlargement  of  the  Gall-bladder  from  Accumulation  of  Gall- 
stones. 

Gall-stones  sometimes  accumulate  in  the  gall-bladder  in 
such  quantity  as  to  form  a  distinct  tumour  (see  p.  488). 
This  form  of  enlargement  may  be  recognised  by  these  charac- 
ters : — 

1.  It  is  hard  and  sometimes  nodulated. . 

2.  It  is  usually  movable. 

3.  Although  often  a  centre  of  uneasy  sensations  (see  p.  488), 
it  is  painless  on  pressure. 

4.  Occasionally  a  crackling  sensation  is  experienced  on 
manipulating  the  tumour,  or  the  patient  complains  of  a  sensa- 
tion of  a  weight  rolling  from  side  to  side  when  he  turns  in  bed 
(see  p.  488). 

5.  There  is  in  many  cases  either  jaundice  or  a  previous 
history  of  biliary  colic. 

6.  Its  size  does  not  vary,  or  its  growth  is  slow  and  imper- 
ceptible. 

7.  The  usual  indications  of  cancer  are  absent. 

These  characters  may  be  modified  when  the  gall-stones  ex- 


526  ENLAEGEMBNTS    OF    THE    GALL-BLADDER  :  lect.  xiii, 

cite  ulceration  of  the  mucous  membrane  or  local  peritonitis. 
The  tumour  may  then  become  painful  and  adherent,  and  may 
increase  in  size. 

Y.  Enlargement  of  the  Gall-bladder  from  Cancerous  Deposit  in  its 

walls. 

Cancer  of  the  gall-bladder  is  sometimes  secondary  to  cancer 
of  the  liver  or  pancreas  (Case  CXXV.  p.  380)  or  of  some  more 
distant  organ  (Case  CLXXV.)  ;  more  commonly  the  disease 
commences  in  the  gall-bladder  and  the  peritoneum  or  liver  is 
affected  secondarily  (Case  CLXXVI.).  It  is  remarkable  that  in 
most  of  these  cases  the  gall-bladder  contains  calculi,  and  the 
cancer  appears  to  be  the  sequel  of  gall-stones  (p.  372).  En- 
largement of  the  gall-bladder  from  cancer  has  the  following 
characters. 

1.  There  is  a  hard,  sometimes  nodulated  tumour,  aboat  the 
size  of  an  oraiige,  more  or  less,  in  the  region  of  the  gall-bladder. 
Occasionally  the  tumour  feels  soft  in  the  centre  from  softening 
of  the  cancerous  matter,  or  from  the  cancer  being  chiefly  at  the 
neck  while  the  fundus  contains  fluid  (Case  CLXXV.). 

2.  It  is  adherent  and  immovable. 

3.  It  is  very  tender  on  pressure,  and  is  usually  the  seat  of 
severe  lancinating  pains. 

4.  Its  growth  may  be  rapid.  Not  unfrequently  there  is  a 
previous  history  of  biliary  colic. 

5.  Jaundice  and  vomiting  are  common  symptoms,  owing  to 
the  extension  of  the  cancer  to  the  common  bile-duct  or  to  the 
pressure  of  the  tumour  on  the  pylorus. 

6.  Fistulous  communications  with  the  digestive  canal,  and 
particularly  with  the  colon,  are  not  uncommon,  and  conse- 
quently the  passage  of  a  large  gall-stone,  with  or  without  ha3- 
morrhage  per  anum,  concurring  with  a  tumour  like  that  now 
described  would  corroborate  rather  than  refute  the  diagnosis  of 
cancer  (see  p.  499). 

7.  There  is  rapid  emaciation  with  the  usual  phenomena  of 
the  cancerous  cachexia. 

Treatment  of  Enlargement  of  the  Gall-bladder. 

1.  The  treatment  of  over-distension  of  the  gall-bladder  with 
bile  has  been  already  considered  under  that  of  jaundice  from 
obstruction  of  the  bile-duct.     (See  p.  365.) 

2.  In  the  course  of  this  lecture  I  have  told  you  Avhat  mea- 


X-ECT.  xin.  THEIR   VAEIETIES    AND    CHARACTERS.  ^2J 

sures  you  must  have  recourse  to  in  inflammation  of  the  gall- 
bladder.    It  now  only  remains  for  me  to  add  : — 

a.  That  in  all  such  cases  the  patient  must  be  cautioned 
against  the  risk  of  a  severe  muscular  strain  or  a  slight  blow. 
Cases  have  been  recorded  where  from  such  causes  the  gall- 
bladder has  been  ruptured  and  fatal  peritonitis  has  been  the 
result.^ 

h.  That  now  and  then  it  will  be  necessary  to  puncture  the 
gall-bladder  and  evacua.te  its  contents  (see  Case  CLXX.),  but 
that  this  ought  never  to  be  done  except  when  the  tumour  is 
growing  so  rapidly  that  there  is  imminent  danger  of  its  bursting-, 
or  the  constitution  is  being  worn  out  by  hectic  fever.  From 
what  has  been  stated  it  is  also  obvious  that  the  operation  is 
rarely  advisable  when  there  is  jaundice  with  absence  of  bile 
from  the  motions.  If  there  be  no  adhesions  over  the  tumour 
it  will  be  necessary  to  produce  them  by  means  of  caustic 
potash. 

8.  Accumulations  of  gall-stones  in  the  gall-bladder  must  be 
treated  in  the  manner  already  described  (see  p.  504) ;  and 
lastly, 

4.  In  cancerous  enlargement  all  that  can  be  done  is  to  re- 
lieve distressing  symptoms  and  promote  euthanasia. 

In  conclusion,  I  may  bring  under  your  notice  the  two  fol- 
lowing cases  of  cancer  of  the  gall-bladder,  which  came  under 
my  observation  a  few  years  ago  and  were  reported  by  me  in  the 
eighth  volume  of  the  Pathological  Transactions.  In  one  case 
the  cancer  of  the  gall-bladder  was  secondary  to  cancer  of  the 
rectum  and  liver ;  in  the  other  the  cancer  of  the  liver  appeared 
secondary  to  that  in  the  gall-bladder. 

Case  CLXXV.- — Gancer  of  Rectum— Secondary  Cancer  of  Liver  involv- 
ing Gall-Bladder  and  obliterating  Cystic  Duct — Enlargement  of  Gall- 
hladder. 

A.  B ,  a  female  aged  53,  was  admitted  into  St.  Mary's  Hospital 

on  Aug.  29,  1856.  She  had  been  suffering  from  pains  in  loins  and  ab- 
domen for  two  months,  and  on  admission  she  had  also  slight  jaundice 
and  constipation.  Liver  was  not  enlarged,  but  a  tumour,  size  of  a 
small  orange,  projected  from  lower  border  in  site  of  gall-bladder. 
These  symptoms  increased,  and  a  week  after  there  was  superadded 
uncontrollable  vomiting.     All  treatment  proved  unavailing ;  jaundice 

'  There  is  a  preparation  showing  t'ais  in  the  Museum  of  St.  Bartholomew's 
Hospital,  ser.  xia..  No,  14. 


52  8  EN"LARGEME]!7TS    OF    THE    GALL-BLADDER:  lect.  xiii. 

became  more  marked,  constipation  more  confirmed,  and  patient  grew 
gradually  weaker  till  death,  on  Sept.  28. 

On  post-mortem  examination,  small  nodules  of  cancer  scattered 
over  peritoneal  surface  of  intestines.  A  stricture  of  rectum  from 
similar  deposit  commencing  1^  in.  from  anus  and  extending  upwards 
for  3  in.  Only  portion  of  liver  affected  was  lobus  quadratus.  In  this 
there  was  a  cancerous  deposit,  size  of  a  small  orange,  which  involved, 
and  had  obliteiated,  cystic  duct.  Coats  of  gall-bladder  for  one-fourth 
of  their  extent  from  duct  were  thickened  by  deposit;  anterior  three- 
fourths  free  from  disease  ;  whole  gall-bladder  was  of  a  pale  colour, 
and  much  distended,  so  as  to  project  two  inches  in  front  of  anterior 
margin  of  liver;  it  contained  a  milky  flaky  fluid,  exhibiting  under 
microscope  numerous  epithelial  scales  and  two  gall-stones  about  size 
of  marbles.  No  trace  of  ulceration  in  any  part  of  its  lining  membrane, 
and  no  adhesion  between  its  outer  surface  and  any  of  viscera.  Bile 
in  duodenum.  Mucous  membrane  of  stomach,  the  spleen,  kidneys,  and 
lungs  free  from  disease. 

Case  CLXXVI. — Destructlonhy  Cancerous  Ulceration  of  the  Gall-Madder, 
and  communication  of  resulting  cavity  with  Transverse  Colon — Cancer 
of  Liver. 

S.  P ,  aged  56,  a  coach-painter,  came  under  my  care  on  Aug. 

14,  1856.  He  stated  that,  when  a  young  man,  he  had  an  attack  of 
jaundice  preceded  by  severe  cramps  in  stomach.  Fourteen  years  before 
J  saw  him  he  had  suffered  from  rheumatic  fever,  followed  by  palpita- 
tions and  other  symptoms  of  cardiac  disease.  Father  had  lived  to  a 
great  age,  and  mother  had  died  at  86  of  cancer  of  uterus.  He  was 
his  mother's  last  child,  and  was  born  when  she  was  nearly  50. 

Three  months  before  he  applied  to  me  for  relief  he  began  to  suffer 
for  fir.st  time  from  a  pain  in  region  of  liver,  but  he  continued  regularly 
at  work  till  middle  of  July.     About   this   time  he   was  seized   with 
severe  abdominal  pains,   vomiting,    and    purging.     He    continued    at 
work,    although    irregularly,    for   a  fortnight  longer,   but    on    1st   of 
August  he  was    obliged  to  take  to   bed.     On  August   7    he    became 
jaundiced.     The  following  notes    were  taken  when  he  was  seen   by 
me  on  August  14.     '  Is   very   much  emaciated  ;  conjunctivge  are  of  a 
deep  yellow  colour,  and  countenance  has  an  anxious  cachectic  aspect 
expressive   of  inward   pain.     Tongue  has   a  yellowish  fur  ;  vomiting 
continues,  almost  everything  he  swallows  being  immediately  rejected 
and  sometimes  apparently  before  it  reaches  stomach.     Bowels  relaxed. 
Two  or   three   days  ago,  his  wife   states  that  he  passed   by  stool  a 
quantity  of  bhick   matter  like   blood.     Complains   of  sharp,   shooting 
pain   in  hepatic   region,  coming   on  at  intervals.     Hepatic  dulness  in 
right  mammary  line  extends  four  inches  below   margin   of  ribs,  and 
a    tumour    can   be    felt    in    region    of   gall-bladder,    2    or   8  in.    in 
diameter,  immovable,  apparently  connected  with  liver,  and  very  pain- 


LECT.  xm.  THEIR    VARIETIES    AND    CHARACTERS.  529 

ful  on  pressure.     Patient  does  not  sleep  on  account  of  pain  ;  pulse  100. 
A  diastolic  blowing  murmur  is  heard  over  the  middle  of  sternum.' 

Was  ordered  milk-diet,  wine,  ojoiates,  and  various  remedies  to  check 
vomiting,  including  naphtha  and  dilute  hydrocyanic  acid.  Nothing, 
however,  proved  of  any  avail ;  he  gradually  sank,  and  died  on  Aug. 
19.  Previous  to  death  stools  had  assumed  a  perfectly  natural  colour 
and  consistence. 

Autopsy. — Opaque  patches  on  surface  of  heart  and  several  small 
vegetations  on  both  mitral  and  aortic  valves.     Lungs  healthy. 

No  effusion  in  peritoneum  ;  spleen  and  kidneys  normal.  Scattered 
throughout  substance  and  over  surface  of  liver  were  a  number  of 
small  white  masses  of  morbid  deposit,  varying  in  size  from  that  of  a 
pea  to  that  of  a  small  orange.  Those  on  surface  umbilicated  in  centre, 
and  from  all  of  them  exuded  on  pressure  a  milky  juice  containing  a 
multitude  of  '  cancer-cells'  and  free  nnclei.  These  cells  varied  in  size 
from  3-^  to  ^  3\,  (J  of  an  inch,  and  in  form  were  rounded,  elliptical, 
fusiform,  pear-shaped,  &c.,  while  their  nuclei  were  large  and  well 
defined.  Among  them  were  a  few  '  mother-cells.'  Transverse  colon 
firmly  adherent  to  anterior  margin  of  liver,  at  a  part  corresponding  to 
situation  of  gall-bladder ;  and  on  slitting  up  bowel,  its  interior  was 
found  to  communicate  by  an  opening  as  large  as  a  half-penny  piece 
with  a  cavity  hollowed  out  in  substance  of  liver,  measuring  2-|^  in.  from 
before  backwards  and  \\  in.  from  side  to  side.  Walls  of  this  cavity 
presented  an  irregular  sloughy  aspect,  being  composed  of  disintegrated 
hepatic  and  cancerous  tissue,  and  interior  filled  with  a  dark- brown 
pultaceous  fluid  containing  a  piece  of  potato-skin  and  other  debris  of 
food.  This  cavity  corresponded  exactly  in  position  to  site  of  gall- 
bladder, no  trace  of  walls  of  which  could  be  seen  ;  remains  of  obliterated 
cystic  duct  and  arteiy  were  made  out  embedded  in  a  mass  of  cancerous 
deposit,  size  of  a  Spanish  chestnut,  which  also  compressed,  but  did  not 
obliterate,  common  hepatic  duct.  Margins  of  opening  in  transverse 
colon  and  whole  circumference  of  corresponding  portion  of  bowel 
thickened  by  deposit  which  narrowed  calibre  of  gut,  so  as  to  produce 
a  stricture  barely  admiting  point  of  finger.  Bowel  above  this  stricture 
much  dilated  and  exhibited  on  its  mucous  surface  a  number  of  super- 
ficial circular  ulcers,  largest  being  about  size  of  a  silver  penny-piece. 
The  continuation  of  gut  beyond  stricture  was  contracted.  No  disease 
of  any  other  portion  of  intestines  or  of  stomach,  but  pylorus  was  com- 
pressed by  cancerous  deposits  in  liver. 


M  M 


530 


LECTUEE  XIV. 

THE   CROONIAN  LECTURES  ON  FUNCTIONAL  DERANGE- 
MENTS  OF  THE  LIVER} 

NOTICE    OF   DOCTOR    CKOONB — PRESENT    NOTIONS    AS    TO    FUNCTIONAL    DERANGEMENTS    OP 

LIVER     UNSATISFACTORY A.     FUNCTIONS      OF     THE     LIVER     IN     HEALTH.        HISTORICAL 

SKETCH  ;  GALHN's  VIEWS  ;  OBSEQUIES  OF  LIVER  BY  BARTHOLIN  ;  MODERN  VIEWS  ; 
FUNCTIONS  OF  LIVER  THREEFOLD.  I.  SANGUIFICATION  AND  NUTRITION.  II.  DISINTE- 
GRATION OF  ALBUMINOUS  MATTER.  III.  SECRETION  OF  BILE  ;  COMPOSITION,  ORIGIN, 
QUANTITY,  AND  USES  OF  BILE.  B.  FUNCTIONAL  DERANGEMENTS  OP  LIVER.  OBJECTIONS 
TO    EXISTING  CLASSIFICATION.       PROPOSED  CLASSIFICATION.       I.    ABNORMAL    NUTRITION. 

1.  corpulence;  2.  emaciation,     a.  deficiency  of  bile;    b.  diabktes  ;  c.  other 

VARIETIES  of  EMACIATION.  II.  ABNORMAL  ELIMINATION  ;  SYMPTOMS  OF  RETAINED 
bile;    CHOLESTEARiEMIA. 

Mr.  President,  Fellows  of  the  College,  and  Gentlemen, — 
It  may  interest  some  of  you  if,  by  wa}'-  of  preface,  I  say  a  few 
words  respecting  the  founder  of  the  course  of  lectures  which  I 
am  h-onoured  by  delivering  before  you.  For  the  particulars  I 
am  indebted  to  the  '  Roll '  of  the  College,  edited  by  our  learned 
colleague  Dr.  Munk. 

Dr.  William  Croone  was  born  in  London  and  educated  at 
Emanuel  College,  Cambridge.  He  became  a  Fellow  of  this 
College  on  July  29,  1675,  and  was  Censor  in  1679.  In  1659  he 
was  elected  Professor  of  Rhetoric  at  Gresham  College,  and 
shortly  afterwards  he  was  made  Secretary  of  the  Royal  Society, 
which  then  held  its  meetings  in  Gresham  College.  He  resigned 
his  professorship  in  1670,  on  being  appointed  Lecturer  on  Ana- 
tomy at  Surgeons'  Hall.  He  died  in  1684,  and  was  buried  in 
the  churchyard  of  St.  Mildred's  in  the  Poultry.  He  left  behind 
him  a  plan  for  two  lectureships,  which  he  had  designed  to  found 
— one  course  of  lectures  to  be  read  before  the  College  of  Pliysi- 
cianSj.after  a  sermon  to  be  preached  in  the  church  of  St.  Mury- 
le-Bow ;  the  other  to  be  delivered  yearly  before  the  Royal 
Sociecy,  upon  the  nature  and  laws  of  muscular  motion.  His 
will  contained  no  provision  for  the  endowment  of  these  lectures  ; 
but  his  widow  (a  daughter  of  Alderman  Lorimer,  who  subse- 
quently married  Sir  Edwin  Sadleir,  Bart.)  canied  out  hisinten- 

'  Dulivcrod  before  tlic  lloyiil  College  of  Physicians  in  1874. 


LECT.  XIV.  INTRODUCTOET   REMARKS.  53 1 

tion  by  devising  in  lier  will  the  King's  Head  Tavern  on  Larabeth 
Hill,  Knight  Rider  Street,  in  trust  to  her  executors,  to  settle 
four  parts  out  of  five  upon  the  College  of  Physicians  for  the 
purpose  of  founding  the  annual  lectures  now  known  as  the 
Croonian  Lectures,  and  the  fifth  part  to  found  the  Croon ian 
Lecture  of  the  Eoyal  Society.  A  fine  portrait  of  Dr.  Croone 
was  presented  to  the  College  in  1 738  by  Dr.  Woodford,  Regius 
Professor  of  Physic  at  Oxford,  and  is  now  suspended  in  the 
Censors'  room. 

The  founder  of  these  lectures  made  no  restriction  as  to  their 
subject,  as  he  did  with  regard  to  the  lecture  before  the  Royal 
Society ;  and  it  has  been  customary  for  each  lecturer  to  select 
some  subject  in  practical  medicine  which  his  experience  has 
been  most  calculated  to  elucidate.  The  subject  which  I  have 
chosen  is  one  which  it  appears  to  me  is  well  worthy  of  the 
attention  of  this  College,  and  of  medical  men  in  general, 
viz..  The  Functional  Derangements  of  the  Liver.  Professional 
opinion  as  to  what  constitutes  functional  disorder  of  the  liver 
is  vague  and  unsatisfactory.  There  is  no  expression  more 
common  among  both  patients  and  their  doctors  than  that  the 
'liver  is  out  of  order,'  or  that  certain  symptoms  are  due  to 
*  biliousness,'  and-  yet  few  medical  writers  have  undertaken  to 
define  with  accuracy  what  symptoms  are  referable  to  a  disordered 
liver.  It  is  to  be  feared  that  symptoms  are  sometimes  referred 
to  the  liver,  with  which  it  has  little  or  no  concern ;  while,  on 
the  other  hand,  there  are  grounds  for  suspecting  that  many 
symptoms,  at  first  sight  apparently  referable  to  other  organs, 
and  even  grave  degenerations  of  tissue  and  organic  disease,  not 
only  of  the  liver  itself,  but  throughout  the  body,  may  be  traced 
back  to  functional  derangements  of  the  liver,  although  some  of 
these  may  as  yet  be  imperfectly  understood.  It  is  remarkable 
how  systematic  writers  on  Medicine  and  on  Diseases  of  the 
Liver  in  particular  entirely  ignore  the  subject  of  functional 
disorders  of  the  liver.  The  remarks  which  follow  must  be 
regarded  as  a  feeble  attempt  to  sketch,  with  the  light  of  recent 
investigation,  those  symptoms  and  morbid  conditions  which  may 
fairly  be  put  down  to  a  disordered  liver.  They  do  not  pretend 
to  place  the  subject  upon  a  firm  and  lasting  basis ;  but,  by 
calling  attention  to  its  importance  and  provoking  discussion,  it 
is  hoped  that  they  will  prove  a  stepping-stone  to  a  more  certain 
knowledge  of  it,  and  in  the  meantime  that  they  will  help  to 
supply  what  appears  to  be  a  d*^ficiency  in  medical  literature. 


532  FUNCTIONAL    DEEANGEMEXTS    OF    THE    LIVER.       lect.  siv. 

A.     FUNCTIONS    OF    THE    LIVER    IN    HEALTH. 

Before  proceeding  to  discuss  tLe  results  of  derangement  of 
tlie  liver,  it  will  be  necessary  for  me  to  refer  at  some  length  to 
the  functions  of  the  organ  in  its  healthy  state.  As  in  the  case 
of  the  pathology  of  pyrexia  and  of  inflammation,  so  with  regard 
to  the  healthy  functions  of  the  liver,  it  is  not  a  little  remark- 
able that  modern  investigations  have  tended  to  reproduce  in  a 
scientific  form  certain  crude  opinions  entertained  by  the  earliest 
writers  on  Medicine.  From  its  large  size,  and  from  the  exten- 
sive system  of  blood-vessels  connected  with  it,  the  liver  was 
believed  by  the  Fathers  of  Medical  Science  to  be  the  seat  of 
many  most  important  functions,  and  to  be,  in  fact,  the  central 
organ  of  vegetative  life.  Galen,  for  example,  taught  that  the 
liver  was  the  centre  of  animal  heat,  that  it  was  the  seat  of 
sanguification,  and  that  it  was  the  starting  point  of  the  venous 
system.  He  assigned  to  the  veins  distributed  over  the  intes- 
tines the  function  of  imbibing  the  fluid  nutriment  and  of  con- 
veying it  by  the  vena  portse  to  the  liver,  where  he  supposed 
that  the  processes  of  sanguiflcation  and  of  the  generation  of 
animal  heat  took  place.  He  then  traced  the  passage  of  the 
blood  through  the  hepatic  veins  to  the  heart,  and  hence  he 
regarded  the  liver  as  the  starting  point  of  the  venous  system. 
For  upwards  of  sixteen  centuries  these  views  of  Galen — more 
or  less  modified — were  generally  accepted  by  physiologists  and 
physicians,  and  as  late  as  the  seventeenth  century  they  were 
iu  the  main  upheld  by  our  own  Harvey.  But  the  discovery  in 
the  first  half  of  the  seventeenth  century  of  the  lacteals  and 
thoracic  duct  showed  that  chyle  was  conveyed  to  the  blood 
independently  of  the  portal  vein  and  of  the  liver.  The  result 
was  that  this  organ  at  once  fell  from  its  high  estate,  and  ceased 
to  be  regarded  as  serving  any  purpose  in  sanguification. 
Thomas  Bartholin,  in  his  '  Defence  of  the  Lacteals  and  Lym- 
phatics against  Riolanus,'  wrote  for  the  liver  an  epitaph,  in 
which  the  end  of  its  dominion  was  announced,  and  its  function 
was  declared  to  be  henceforth  limited  to  the  secretion  of  bile. 

Yivit,  flo^e^quo  pro  Viile  separand4,  sed,  si  Siinguinetn  conficiendum  spectoniiis, 
fuDerntum  crcditur.     I\  imu.s  illi  exsequias,  nuiiqmim  redituro.     Nam   .... 

Facilis  descensus  Averni, 

Sed  rcvocari'  firadum,  superasque  eradero  ad  auras 
Hoc  opus,  hie  labcir.' 

'  Defcnsio  vasorum  lactconim  ct  lymi^liaticorum  advcrsus  J.  Riolanum.     Hafuiae 
1C5.3,  p.  8.   • 


LECT.  XIV.  FUNCTIONS    OF    THE    LIVER   IN   HEALTH.  533 

Altlioug'li  it  was  a  priori  improbable  that  the  largest  gland 
in  the  body,  deriving  large  supplies  of   blood  from  different 
sources  as  well  as  holding  peculiar  relations  to  the  blood  re- 
turning from  the  placenta  in  the  foetus  and  from  the  stomach 
and  intestines  in  the  adult,  should  have  as  its  sole  function  the 
secretion  of  a  fluid  which  is  apparently  of  less  importance  in 
digestion  than  the  gastric  or  pancreatic  juice,  yet  for  nearly  two 
centuries  the  only  object  of  the  liver  was  believed  to  be  the 
secretion  of  bile  :  and  down  to  the  present  day  its  functional 
derangements  are  constantly  spoken  of  as  restricted  to  the  se- 
cretion of  bile  abnormal  in  quantity  or  in  quality.    For  example, 
our  late  learned  colleague  Dr.  Copland,  one  of  the  few  modern 
medical  authors  who  have  discussed  the  functional  disorders  of 
the  liver,  describes  them  as  coming  under  three  heads,  viz. :  1. 
Diminished  secretion  of  bile :  2.  Increased  secretion  of  bile  ; 
and  3.  Secretion  of  morbid  or  altered  bile ;  ^  and  this  classifica- 
tion probably  represents  with  tolerable  accuracy  the  views  of  the 
great  majority  of  modern  practitioners  of  medicine.     It  is  the 
belief  that  the  sole  function  of  the  liver  is  the  secretion  of  bile 
which  has  given  rise  to  the  expression  in  common  use  by  profes- 
sional men  as  well  as  laymen,  that  the  '  liver  will  not  act,'  when 
ail  that  is  implied  is  a  constipated  state  of  the  bowels.     But  the 
physiological  investigations  made  within  the  last  quarter  of  a 
century  have  in  a  great  measure  restored  the  liver  to  its  former 
place  of  importance  in  the  animal  economy ;  they  have  shown 
that  the  secretion  and  excretion  of  bile  are  far  from  being  the 
most,  if  they  be  not  the  least,  important  of  its  functions ;  and 
they  have  consequently  added  to  the  number  of  its  functional 
derangements. 

I.  In  the  first  place  it  is  now  known  that  the  liver  is  one  of 
the  organs  mainly  concerned  in  the  process  of  sanguification. 
So  long  ago  as  1820,  it  was  shown  by  Magendie  andTiedemann 
that  the  absorption  of  nutritive  matters  from  the  bowel  was 
not  limited  to  the  lacteals,  but  that  part  was  taken  up  into  the 
blood  through  the  portal  vein  ;  ^  and  the  researches  of  subse- 
quent physiologists  have  clearly  established  that  the  liver  exer- 
cises most  important  functions  in  assimilation  and  nutrition. 
The  most  valuable  contributions  towards  our  knowledsre  of  this 
matter  have  been  the  researches  of  Claude  Bernard  and  other 

1  Medical  Dictionary,  ii.  723. 

"^  Versucbe  iiber  die  Wege  auf  welclien   Sul'stanzen  aus  dem  Magen  und  Carni- 
Canal  im  Blut  gelangen.     Heidelberg,  1820. 


534  FUNCTIOlSrAL    DEEANGEMENTS    OF    THE    LIVEE.       lect.  xiv. 

observers,  who  liave  shown  that  the  liver  has  the  power  of 
making'  and  storing  up  for  a  time  within  its  cells  glycogen 
(CH'^O^),  a  substance  resembling  dextrin  (C^H^^O^)  in  its 
chemical  composition  and  reactions,  and  like  it  capable  of  con- 
version into  sugar  by  the  action  of  albuminoid  ferments.  This 
substance  always  exists  in  the  liver  in  larger  amount  during 
digestion  than  during  fasting,  attaining  its  maximum  usually 
about  four  or  five  hours  aiter  a  meal.  It  does  not  yet  seem  cer- 
tain what  the  materials  are  from  which  it  is  mainly  formed,  but 
there  can  be  no  doubt  that  its  amount  is  increased  by  the  use 
of  starchy  or  saccharine  food.  The  starch  (C^H^^O^)  of  the 
food  is  believed  to  be  converted  into  grape-sugar  or  glucose 
(C^H^^O^)  by  the  saliva  and  pancreatic  secretion,  while  the 
cane-sugar  (C^^H^^O^^)  is  transformed  by  the  intestinal  secretion 
into  grape-sugar  and  another  form  of  sugar  called  Isevulose 
^QGgi2Q6j^  The  glucose  and  laevulose  are  absorbed  by  the  in- 
testinal veins  and  carried  by  the  portal  vein  to  the  liver,  where 
they  are  converted  partly  perhaps  into  fat,  but  mainly  into 
glycogen,  which  is  stored  up  in  the  hepatic  cells,  and  distributed 
for  the  nutrition  of  the  tissues  during  the  intervals  of  fasting. 
The  circumstance,  however,  of  glycogen  being  formed  in  con- 
siderable quantity  in  the  livers  of  animals  who  have  been  fed 
for  a  month  or  more  on  flesh  alone,  and  the  fact  that  its  quan- 
tity in  the  liver  of  a  dog  is  always  increased  after  a  meal  ot 
flesh,  show  that  it  can  also  be  produced  from  albuminous 
matter.  The  albumen  of  the  food  is  converted  by  the  gastric 
juice  into  pej)tone,  which  is  also  absorbed  by  the  intestinal 
veins  and  carried  to  the  liver,  where  it  is  believed  to  be  decom- 
posed into  glycogen  and  nitrogenous  products  such  as  leucin 
(C^H'^JSTO^)  andtyrosin  (C^H'^NO^),  which  are  ultimately  resolved 
into  urea  (CH^IST''^  0).^  The  glycogen  derived  from  these  two 
sources  does  not  remain  long  in  the  liver,  for  the  large  quantity 
formed  after  a  meal  is  quickly  diminished  on  fasting.  It  is  not 
got  rid  of  by  the  bile-ducts,  for  bile  contains  neither  glycogen 
nor  sugar.     But  either  as  glycogen,  or  more  probably  as  sugar,^ 

'  See  Fick  in  Pfliigor's  Arcliiv,  vol.  iv.  p.  40 ;  also  Schult.zen  and  Kcncki,  Zcit- 
schrift  fiir  Biologic,  vol.  viii.  p.  124. 

''■  In  rpforcncc  to  tho  difference  of  opinion  sfill  existing  on  tliis  mutter,  Dr. 
IJrunton  writes  as  follows,  in  tSiinderson's  Hiiudbook  for  tiio  Physiologieiil  Laboratory 
1873,  p.  508  :  '  Wliile  Bernard  considers  that  tho  formation  of  sugar  goes  on  in  the 
liver  constantly  during  life,  this  has  been  denied  by  Pavy,  Ritter,  Meissner,  and 
Sehiff,  wlio  hold  tliat  it  only  occurs  after  death,  or  under  patliological  conditions,  such 
as  disturbance  of  tlie  respiration  or  circulation  during  life.     They  base  their  opinions 


LECT.  XIV.  FUNCTIONS    OF    THE    LIVER    IN    HEALTH.  535 

into  whicli  it  is  believed  by  Bernard  and  most  other  physiologists 
to  be  reconverted  through  the  action  of  an  albuminoid  ferment 
in  the  liver  or  in  the  blood,  or  transformed  in  some  other  way,  it 
enters  the  blood  by  the  hepatic  veins. 

One  object  of  the  glycogenic  function  of  the  liver  is  supposed 
to  be  that  of  continuously  supplying  an  easily  oxydisable  ma- 
terial, such  as  sugar,  which,  in  the  presence  of  oxygen  and 
albuminous  matter,  is  readily  converted  in  the  lungs  into 
carbonic  acid  and  water  and  thus  contributes  to  the  main- 
tenance of  animal  heat.  But  although  there  is  still  some 
difference  of  opinion  among  those  most  competent  to  judge,  the 
bulk  of  evidence  goes  to  show  that  a  portion  only  of  the  gly- 
cogen formed  in  the  liver  is  transformed  into  sugar  to  be  burnt 
in  the  lungs,  and  that  the  maintenance  of  animal  heat  is  far 
from  being  its  chief  use.  There  are  good  grounds  for  believing 
that  it  assists  in  cell-growth  ;  for,  just  as  in  plants  the  presence 
of  sugar  seems  to  be  necessary  for  the  most  rapid  development 
of  cells,  so  in  animals  glycogen  can  be  found  wherever  cell- 
growth  is  actively  going  on.  Bernard  and  Eouget  have  found 
it  in  abundance  in  the  cells  of  the  placenta  and  amnion ;  and 
Eouget  in  many  foetal  tissues,  such  as  cartilage,  muscle, 
and  the  epithelial  cells  of  the  skin  ; '  and  it  is  also  present  in 
the  inflammatory  products  of  pneumonia,  which  are  mainly 
made  up  of  leucocytes,  and  in  new  growths  whenever  cell-for- 
mation is  active.  Hoppe-Seyler  has  also  shown  that  it  is  an 
ingredient  of  colourless  blood-corpuscles,  so  long  as  they  are 
active,  but  that  when  they  lose  their  power  of  motion  the 
glycogen  disappears  and  is  replaced  by  sugar.^     In  connection 

on  the  observations  that  the  liver  contains  little  or  no  sugar  when  examined  imme- 
diately after  death,  and  that  the  blood  of  t!ie  hepatic  vein  does  not  contain  more  sugar 
than  that  of  the  portal  or  jugular  veins.  It  is  quite  true  that  sugar  is  found  in  very 
small  amount  in  fresh  livers  ;  but  the  smallness  of  the  quantity  is  in  all  probability 
due  to  the  constant  circidation  tlirough  the  liver  during  life  washing  the  sugar  oiit  of 
it  as  soon  as  it  is  formed  (Flint).  The  statement  that  the  blood  of  the  portal  contains 
as  much  sugar  as  that  of  the  hepatic  vein  rests  on  experiments  vitiated  by  the  omission 
to  place  a  ligature  on  the  former  while  removing  the  liver,  so  that,  the  hepatic  vein 
having  no  valves,  the  blood  from  it  flowed  back  into  the  portal  system.  When  this 
fallacy  is  avoided,  sugar  is  found  in  much  larger  proportion  in  the  hepatic  than  in 
the  portal  vein.  To  meet  the  objection  that  sugar  thus  found  has  been  formed  after 
death,  blood  has  been  taken  from  the  right  side  of  the  heart,  or  vena  cava,  and  the 
quantity  of  sugar  it  contained  compared  with  a  similar  specimen  of  blood  from  the 
jugular  vein.  Every  precaution  was  taken  to  avoid  disturbance  of  the  circulation,  yet 
the  sugar  in  the  former  was  found  to  exceed  that  in  the  latter  considerably  (Lusk).' 

'  Journal  de  Physiologie,  18o9,  tome  ii. 

2  jVIed.  Chem.  Untersuch.  1871,  p.  486. 


53^  FUNCTIONAL   DEBANGEMENTS    OP   THE    LIVER.       lect.  xiv. 

•with  these  ohservations,  it  is  important  to  note  that  the  blood, 
on  emerging  from  the  liver,  is  much  denser  and  contains  a  far 
larger  proportion  of  solid  constituents  (although  less  fibrin),  and 
is  also  far  richer  in  white  blood- corpuscles,  than  the  blood 
before  it  enters  the  liver.  Bernard,  Lehmaiin,  and  McDonnell 
ascertained  that  in  blood  drawn  from  the  hepatic  vein,  the 
colourless  corpuscles  are  from  five  to  ten  times  more  numerous 
than  in  blood  taken  from  the  portal  vein;  ^  while  Hirtof  Zittau 
estimated  that  the  proportion  of  the  colourless  to  the  red  cor- 
puscles was  in  the  portal  venous  blood  as  1  to  524,  but  in  the 
hepatic  as  1  to  136.^  The  red  corpuscles  also  from  the  hepatic 
vein  are  said  to  have  a  sharper  outline  and  less  tendency  to  aggre- 
gate into  rolls,  and  to  dissolve  less  readily  in  water  than  those 
from  the  portal  vein.  Again,  we  have  the  remarkable  observa- 
tions of  Weber,  confirmed  by  Kolliker,  respecting  the  extensive 
generation  of  blood-corpuscles  in  the  liver  of  the  embryo.  In 
the  early  stages  of  foetal  life  the  blood-cells  multiply  throughout 
the  entire  mass  of  the  blood ;  but  when  the  liver  begins  to  be 
formed  this  process  ceases,  and  a  very  active  formation  of 
colourless  blood-cells  is  set  up  in  the  liver,  these  colourless 
cells  undergoing  a  gradual  change  by  the  development  of 
colouring  matter  in  their  interior  into  red  corpuscles.  Ac- 
cording to  Kolliker,  this  new  formation  of  blood-corpuscles 
in  the  liver  continues  during  the  whole  of  the  foetal  life  of 
mammalia.^  The  observations  quoted  above  make  it  probable 
that  the  liver  in  the  adult  continues  to  perform  the  functions 
■which  pertain  to  many  different  tissues  of  the  foetus,  the  gly- 
cogen secreted  in  its  cells  combining  with  nitrogen  and  forming 
an  azotised  protoplasm,  which  maintains  the  nutrition  of  the 
blood  and  tissues.  Dr.  R.  McDonnell  has  suggested  that  part 
of  the  glycogen  of  the  liver  combines  with  nitrogen  furnished 
by  the  fibrin  of  the  blood,  which  is  disintegrated  in  its  passage 
through  the  liver,  and  that  the  result  is  a  new  protein  substance 
which  enters  the  circulation.'*  Our  colleague  Dr.  Pavy  is  also 
of  opinion  that  glycogen  is  capable  of  transformation  into  fat. 
As  he  contends,  it  is  beyond  dispute  that  starch  and  sugar 

'  See  McDonnell's  Observations  on  the  Functions  of  the  Liver.     Dublin,  1865. 

*  Miillcr's  Archiv,  IS-'JS;  and  Carpenter's  Principles  of  Human  Phj'siology,  7th 
edition,  p.  228. 

'  Todd  and  Bowman's  Physiology,  1856,  ii.  263  ;  Carpenter's  Principles  of  Human 
Physiology,  7th  edition,  1869,  p.  214;  and  KoUiker's  Manual  of  Iluman  Histology, 
Sydenham  iSociety  edition,  1854,  vol.  ii.  p.  342. 

♦  Op.  cit. 


XECT.  XIV.  FUNCTIOISrS    OF    TEE    LIVER   IN    HEALTH.  537 

introduced  with,  the  food  lead  in  the  animal  system  to  the  pro- 
duction of  fat,  while  his  experiments  have  shown  that  the 
ingestion  of  these  principles  is  followed  by  a  marked  increase  in 
the  amount  of  glj^cogen  in  the  liver.'  The  production  of 
glycogen,  then,  may  be  regarded  as  the  first  step  in  the  assimi- 
lation of  the  starchy  and  saccharine  elements  of  our  food  :  and, 
as  these  elements  are  kn6wn  to  proceed  on  to  fat,  glycogen 
would  seem  to  occupy  a  position  intermediate  between  the  two. 
The  process  of  assimilation  may  go  on  to  the  production  of  fat 
in  the  liver,  or  it  may  stop  short  at  the  formation  of  another 
principle,  which  escapes  from  the  liver  and  is  elsewhere  trans- 
formed into  fat.  Lastl}^,  there  are  good  grounds  for  thinking 
that  both  glycogen  and  sugar  serve  some  purpose  in  muscular 
action ;  at  all  events,  it  has  been  found  that  the  quantity  of 
sugar  in  blood  becomes  greatly  diminished  in  passing  through 
the  vessels  of  contracting  muscles.''^  According  to  Bernard, 
this  destruction  of  sugar  in  muscle  is  due  to  lactic  fermen- 
tation.^ 

There  may  be  other  ways  in  which  the  liver  contributes  to 
assimilation  and  the  nutrition  of  the  body ;  but  enough  has 
been  said  to  justify  us,  notwithstanding  the  prediction  of 
Bartholin,  in  restoring  to  the  organ  the  important  function 
claimed  for  it  by  Galen  and  his  successors,  viz.,  that  of  sanguifi- 
cation. 

II.  But,  in  the  second  place,  modern  research  has  made  it 
probable  that  the  liver  is  endowed  with  a  function  not  suspected 
by  Galen,  and  which,  from  a  pathological  point  of  view,  is  even 
more  important  than  that  which  we  have  been  considering. 
Many  observations,  pathological  as  well  as  physiological,  point 
to  the  conclusion  that  the  liver  is  not  only  a  blood-forming,  but 
a  blood-destroying  or  purifying  organ,  and  that  it  contributes 
in  a  great  degree  to  the  destruction  of  albuminous  matter 
derived  from  the  food  and  textures,  and  the  formation  of  lu'ea 
and  lithic  acid,  which  are  subsequently  eliminated  by  the 
kidneys.  First,  there  seems  to  be  little  doubt  that  the  albumen 
and  fibrin  of  the  blood  become  largely  disintegrated  in  the 
liver.  Lehmann  and  Bernard  have  shown  that,  while  portal 
blood  contains  much  fibrin,  blood  from  the  hepatic  vein  con- 

1  F.  W.  Pavy,  The  Nature  and  Treatment  of  Diabetes,  2nd  ed.  1869,  p.  113. 
^  Sanderson's  Handbook  for  tlie  Physiological  Laboratory,  1873,  p.  608. 
'  Lectures  delivered  at  the  College  of  France,  London  Medical  Record,  October 
and  November,  1873. 


538  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVEE.       lect.  xiv. 

tains  little  or  none.'  Brown-Seqnard  has  calculated  that  no 
less  a  quantity  than  2,690  grammes,  or  about  86^  oz.,  of 
fibrin  is  daily  lost  to  the  blood  in  its  passage  through  the 
digestive  organs  and  the  liver.^  If  this  be  so,  we  can  readily 
understand  that,  when  anything  occurs  to  interfere  with  this 
fibrin -destroying  function,  there  should  be  a  rapid  increase  of 
fibrin  in  the  blood,  as  we  know  to  occur  in  acui:e  rheumatism 
and  in  other  diseased  states.  Moreover,  there  are  grounds  for 
believing  that,  while  white  blood-corpuscles  take  their  origin 
in  the  liver,  the  red  corpuscles  are  destroyed  there,  and  that 
the  nitrogenous  colouring  matters  of  the  urine  are  partly  the 
result  of  this  destructive  process.  Grehaut  has  ascertained 
that  there  is  a  positive  destruction  of  haemoglobin  in  the 
passage  of  blood  through  the  liver.^  Red  blood-corpuscles  are 
known  to  be  at  once  destroyed  when  brought  in  contact  with  a 
solution  of  bile-acids  of  a  certain  strength  (12  per  cent.,  Legg  ),* 
while  the  researches  of  our  late  colleague  Dr.  Bence  Jones  make 
it  very  probable  that  the  various  shades  of  yellow,  brown,  and 
pink  presented  by  the  sediments  of  the  urine  are  due  to  different 
degrees  of  oxidation  of  the  pigment  of  the  bile.^  But,  secondly, 
there  is  evidence  that  the  liver  is  largely  concerned  in  the 
formation  of  the  nitrogenous  matters  which  are  eliminated  by 
the  kidneys. 

1.  First,  there  is  the  well-known  fact,  to  which  I  shall  have 
occasion  to  refer  again  in  more  detail,  that  among  the  most 
constant  signs  of  functional  derangement  of  the  liver  is  an 
imperfect  formation  of  urea,  evidenced  by  the  deposit  of  lithic 
acid  or  litbates  and  of  a  dark  colouring  matter  closely  allied 
to  lithic  acid  in  the  urine. 

2.  Secondly,  when  a  great  part  of  the  liver  has  been  de- 
stroyed by  disease,  the  urea  discharged  in  the  urine  becomes 
greatly  lessened,  or  it  entirely  disappears.  For  example,  when 
a  great  part  of  the  liver  has  been  destroyed  by  cancer,  there 

'  McDonnell,  op.  cit.  p.  29  ;  G.  Budd,  Diseases  of  the  Liver,  3rd  ed.  1857,  p. 
47. 

2  Journal  de  Pliysiologie,  i.  304.  ^  Sanderson,  op.  cit.  p.  498. 

■•  Kuhne,  Arcliiv  fiir  path.  Anat.  18.58,  Bd.  xiv.  p.  324;  Eobin,  Memoires  lus  a 
la  Socidt6  de  Biologie  pendant  I'Ann^e  1857  ;  and  Dr.  J.  W.  Legg,  Bartholomew's 
Hospital  Bcports,  vol.  ix.  1873. 

*  G.  Budd,  op.  cit.  p.  34;  Sanderson,  op.  cit.  p.  499.  '  The  very  close  resemblance 
of  urine-pigment  to  bilifulvin  is  strongly  suggestive  of  an  hepatic  origin.  .  .  ,  An  ar- 
gument in  favour  of  a  liver  origin  may  perhaps  be  drawn  from  the  effect  of  liver- 
diseases  on  the  urinary  pigment.'     (I'arkes,  On  the  Urine,  1860,  p.  30.) 


IJ5CT.  XIV.  FUNCTIONS    OF    THE    LIVER   IN    HEALTH.  539 

tas  been  found  to  be  a  remarkable  diminution  of  urea.^  Thirty 
years  ago,  our  colleague  Dr.  Parkes  examined  tbe  urine  in  a 
number  of  cases  of  hepatitis  and  bepatic  abscess  in  India,  and 
found  tbat  in  some  instances  there  was  abundance  of  urea,  and 
in  others  scarcely  any,  while  in  some  it  was  altogether  wanting. 
The  cause  of  the  difference  appeared  to  be  the  amount  of 
suppuration.  When  this  was  excessive,  so  that  the  secreting 
substance  of  the  liver  was  almost  entirely  destroyed,  the  amount 
of  urea  was  greatly  lessened,  and  in  a  degree  proportioned  to 
the  extent  to  which  the  glandular  tissue  was  destroyed  by  the 
abscess ;  and,  on  the  contrary,  when  the  liver  was  not  suppu- 
rating, but  was  actively  congested  and  enlarged,  so  that  there 
was  an  increased  activity  of  the  secreting  cells,  the  amount 
both  of  urea  and  lithic  acid  was  increased.^  Again,  in  that 
singular  malady,  acute  atrophy  of  the  liver,  where  every  se- 
creting cell  of  the  liver  becomes  rapidly  disintegrated,  all  trace 
of  urea  may  disappear  from  the  urine,  its  place  being  taken  by 
albuminoid  substances  less  oxidised,  such  as  leucin  and  tyrosin, 
which  are  also  found  in  large 'quantity  in  the  hepatic  tissue,  as 
if  they  marked  the  arrest  or  modification  of  the  transformation 
of  albumen. 2  Lastly,  there  are  grounds,  to  be  referred  to 
presently,  for  believing  that,  when  cerebral  symptoms  supervene 
in  any  case  of  protracted  jaundice  with  destruction  of  the  liver, 
they  are  not  due,  as  has  been  commonly  thought,  to  saturation 
of  the  system  with  bile,  but  to  non-elimination  of  urea.  Eecent 
observations  confirm  in  a  remarkable  manner  the  conclusions 
to  be  drawn  from  what  I  have  just  stated.  M.  Genevoix,  in  a 
recently  published  thesis,^  from  observations  of  his  own,  as  well 
as  from  those  of  MM.  Charcot,  Bouchardat,  and  others,  con- 
cludes that  disorders  of  the  liver  which  do  not  seriously 
implicate  its  secreting  tissue,  such  as  congestion  and  some 
forms  of  jaundice,  increase  the  amount  of  urea  excreted,  while 
the  graver  disorders,  such  as  cancer,  cirrhosis,  and  acute 
atrophy,  diminish  it  very  considerably.  Precisely  the  same 
conclusion  is  arrived  at  by  M.  P.  Brouardel  in  an  elaborate 
memoir  published  in  the  '  Archives  de  Physiologic '  for  A  gust 
and   December,  1876.      Ample  evidence   is  there  adduced  to 

»  Parkes,  On  the  Urine,  1860,  p.  330. 

^  On  the  Dysentery  and  Hepatitis  of  India,  by  E.  A.  Parkes,  1846. 
^  Prerichs,  Klinik  der  Leberkrankheiten,  Ne^v  Sydenham  Society's  translation,  vol.  i. 
p.  221  ;  Murchisou,  Clinical  Lectures  on  Diseases  of  the  Liver,  1868,  p.  229. 
*  Chez  Delahaye,  Paris,  1876. 


540  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVEE.       lect.  xiv. 

show  that  the  quantity  of  urea  voided  in  the  urine  in  twenty- 
four  hours  depends  upon ;  1.  the  activity,  more  or  less,  of  the 
hepatic  circulation ;  and  2.  the  integrity  or  destruction  of  the 
secreting  cells  of  the  liver,  the  quantity  being  always  greatly 
diminished  in  diseases  of  the  liver  which  entail  a  great  destruc- 
tion of  its  secreting  tissue,  such  as  acute  atrophy,  cirrhosis, 
fatty  liver,  &c.  From  these  observations,  it  is  clear,  as  Meiss- 
ner  has  argued,  that  '  withering  and  destruction  of  the  liver- 
tissue  is  connected  with  an  important  diminution  in  the  forma- 
tion of  urea,'  ^  and  that  the  quantity  of  urea  voided  in  the  urine 
furnishes  most  important  evidence  for  grounding  a  prognosis 
in  many  hepatic  disorders. 

3.  There  is  experimental  evidence  that  urea  exists  in  large 
quantity  in  the  liver,  and  that  it  is  formed  there.  Dr.  Partes, 
in  the  Croonian  Lectures  for  1871,^  informed  us  that  the 
experiments  of  Heynsius  and  Stokvis,  followed  up  by  those  of 
Meissner,  Bullard,  Perls,  and  others,  had  placed  on  a  certain 
experimental  basis  the  fact,  that  urea  can  be  largely  found  in 
the  liver ;  while  the  more  recent  observations  of  Cyon  seem  to 
prove  that  there  is  an  actual  production  of  urea  in  the  liver. 
Meissner  discovered  large  quantities  of  uric  acid  in  the  livers  of 
birds,  and  of  urea  in  the  livers  of  dogs  and  cats.  Cyon  ascer- 
tained, on  analysing  blood  obtained  by  introducing  tubes  into 
the  portal  and  hepatic  veins  of  dogs,  that  the  blood  from  the 
latter  vessels  always  contained  much  more  urea  than  that  from 
the  former.  In  one  experiment,  the  blood  from  the  portal  vein 
contained  only  "08  grm.  of  urea  in  ]  00  cubic  centimetres  ;  but, 
after  passing  through  the  liver  once,  it  contained  '14  grm. ;  and, 
after  passing  through  the  liver  four  times,  0*176  grm.  He 
satisfied  himself  also  that  this  increase  was  not  due  merely  to 
washing  out  the  liver,  but  that  there  was  an  actual  formation 
of  urea.^  It  is  important  to  add,  that  the  formation  of  urea  in 
tlie  liver  is  always  greatly  increased  after  food.  Lithic  acid 
has  also  been  found  repeatedly  in  the  liver  of  man  and  mam- 
malia, but  always  in  small  quantity ;  whereas,  in  birds,  in 
which  lithic  acid  takes  the  place  of  urea  as  the  great  eliminator 
of  nitrogen,  it  also  takes  the  place  of  urea  in  the  liver,  as  it 
probably  also  does  in  the  human  liver  under  certain  j)athological 
conditions. 

'  ITcnlc's  Zoitsch.  fur  rationelle  Medicin,  Bd.  x-sxi.  p.  246. 

'■'  Lancet,  1871,  vol.  i.  p.  469. 

'  Centralblatt  I'iir  dio  JMed.  Wissenschaften,  August  1870,  p.  580. 


LECT.  XIV.  FUNCTIONS    OF    THE    LIVER    IN    HEALTH.  54 1 

All  these  observations  point  to  the  liver  as  being  largely 
concerned  in  the  destructive  metamor^^hosis  of  albuminoid 
matter,  the  products  of  which  are  eliminated  by  the  kidneys,^ 
although  it  is  not  improbable  that  other  glandular  organs,  and 
even  the  corpuscles  in  the  circulating  blood,  as  believed  by  H. 
Ludwig  and  Fuhrer,^  may  contribute  to  the  process. 

As  might  have  been  expected,  these  oxydising  and  dis- 
integrative processes,  as  well  as  those  connected  with  the  forma- 
tion of  bile,  are  attended  by  a  production  of  heat.  The  average 
temperature  of  the  body  generally  being  between  98°  and 
99°  Fahr.,  the  temperature  of  the  healthy  liver  reaches  104°, 
or  even,  according  to  Bernard,  sometimes  106°.^  Bernard 
has  also  shown  that  in  dogs  the  temperature  of  the  blood 
in  the  hepatic  veins  is  considerably  higher  than  that  of  the 
blood  of  the  portal  vein,  and  that  the  temperature  of  the 
upper  part  of  the  vena  cava  is  higher  than  that  of  any  other 
part  of  the  body.  This  high  temperature  is  no  doubt  due  to 
the  active  chemical  changes  going  on  in  the  liver;  and,  as  heat 
is  absorbed  during  organisation  and  given  off  during  disinte- 
gration, the  high  temperature  generated  in  the  liver  makes  it 
probable  that  the  disintegrative  processes  taking  place  in  the 
gland  are  in  excess  of  the  formative.  On  the  other  hand,  when 
the  activity  of  the  chemical  changes  in.  the  liver  is  impaired,  as 
after  ligature  of  the  common  duct  or  in  jaundice  from  obstruc- 
tion, the  temperature  of  the  body  is  often  subnormal  (see  p.  319), 
and  in  animals  there  is  no  longer  found  an  increased  tempera- 
ture of  the  blood  in  the  hepatic  veins.  It  follows,  therefore, 
that  the  precise  observation  of  modern  times  has  confirmed  the 
statement  enunciated  centuries  ago  by  Galen,  that  the  liver  is 
a  great  centre  of  animal  heat. 

III.  The  third  function  of  the  liver  is  the  secretion  of  bile. 
The  composition  of  this  substance  is  complex,  and  its  uses  are 
not  yet  sufBciently  known.     Human  bile,  as  found  after  death, 

'  In  jaundice  from  obstniction  of  the  bile-duct  we  have  found  that  the  nutritive 
functions  of  the  liver  are  impaired  or  arrested,  but  it  does  not  follow  that  there  should 
be  a  corresponding  impairment  of  the  destructive  functions  of  the  organ.  The  fact, 
therefore,  that  in  jaundice  from  obstruction  the  elimination  of  urea  by  the  kidneys  is 
in  the  first  instance  but  slightly  diminished,  or  even  increased,  is  no  argument  against 
the  liver  being  concerned  in  its  production.  If  the  jaundice  be  sufficientl}^  protracted, 
non-elimination  of  urea  and  symptoms  of  blood-poisoning  are  not  uncommon. 

2  Parkes,  Lancet,  1871,  vol.  i.  p.  470. 

3  On  the  Heat  of  the  Body.  The  Gulstonian  Lectures  for  1871.  By  Dr.  S.  Gee, 
British  Medical  Journal,  1871,  vol.  i.  p.  330. 


542  FUNCTIONAL    DERANGEMENTS    OE    THE    LIVEE.       lect.  xit. 

is  usually  a  dark  brown  fluid,  of  tenacious  consistence  from  the 
presence  of  mucin,  wHcli  it  derives  from  the  gall-bladder  and 
bile-ducts  ;  but,  when  fresh,  as  it  flows  from  the  liver,  it  is  a 
thin  transparent  liquid,  of  a  golden  yellow  colour  like  that  of 
yolk  of  egg,  of  a  very  bitter  taste,  of  alkaline  reaction,  and 
having  a  specific  gravity  of  about  1018.  It  has  an  unctuous 
feel  and  mixes  freely  with  oil  or  fat.  It  contains  from  9  to  17 
per  cent,  of  solid  matters  (the  proportion  being  always  greater 
soon  after  a  meal),  consisting  for  the  most  part  of  substances 
j)eculiar  to  bile.  Excluding  the  mucin,  its  principal  ingredients 
are — 1.  Bile-pigment;  2.  Biliary  acids  combined  with  soda;  3. 
Cholesterin  and  fats  ,  4.  Mineral  matter,  such  as  phosphates  of 
soda,  potash,  lime,  magnesia,  and  iron,  chloride  of  sodium,  and 
traces  of  copper. 

The  following  analysis  of  bile  obtained  from  a  man  aged  22, 
killed  by  an  injury,  was  made  by  Frerichs  : — 

Water 859'2 

Solid  residue     ..........     140'8 

Glycocholate  of  soda  1                                                              ^  g-^.^ 
Taiirocholate  of  soda  J 

Fat 9-2 

Cholesterin 26 

Bile-pigment  and  mucus  (of  ■which,  mucus  about  1-4)          .         .  29'8 

Salts 77 

The  yellow  pigment  is  designated  hilinibin  (C'^H^^N^O^). 
On  standing,  it  becomes  greenish  from  oxydation  and  is  con- 
verted into  liliverdin  (C"'II'^°N^O^),  which  accounts  for  the  dark 
colour  usually  presented  by  the  bile  in  the  gall-bladder  after 
death  and  in  the  faeces.  Biliverdin  is  also  the  principal  colour- 
ing matter  of  the  bile  of  the  herbivora.  Bilirubin  is  now 
known  to  be  formed  from  blood-pigment  or  hsemoglobin  by  the 
hepatic  cells  in  the  passage  of  the  blood  through  the  liver. 
That  this  was  the  source  of  the  bile-pigment  was  suggested  at 
the  end  of  last  century  by  a  distinguished  Fellow  of  this  College, 
Dr.  W.  Saunders,  who  observed  :  '  Green  and  bitter  bile,  being 
in  common  to  all  animals  with  red  blood,  and  found  only  in 
such,  makes  it  probable  that  there  is  some  relative  connection 
between  this  fluid  and  the  colouring  matter  of  the  blood,  by  the 
red  particles  contributing  more  especially  to  its  formation.'  ' 
This  view,  revived  in  our  own  day  b^'  Virchow,  is  supj)orted  by 
the  apparent  identity  of  bile-pigment  with  the  pigment  hsema- 

'  Trentiseon  the  Structure  and  Disi-ases  of  the  Liver,  3rd  edition,  1803,  p.  147. 


i,ECT.  XIV.         FtnsrCTiONS  of  the  livee  m  health.  543 

toidin  found  in  old  extravasations  of  blood,  and  by  the  fact  that 
what  appears  to  be  bile-pigment  can  be  produced  from  blood- 
pigment  by  the  action  of  chemical  reagents ;  ^  by  the  disco- 
very of  Zenker  and  Frerichs  of  crystals  of  hsematoidin  in  inspis- 
sated bile  and  in  the  bile  of  jaundiced  urine ;  "^  by  the  obser- 
vation of  Gubler  that  bilirubin  and  hsematin  give  the  same  play 
of  colours  with  nitric  acid,  except  that  the  green  colour  is  most 
persistent  in  the  former,  and  the  violet  in  the  latter  ;  ^  by  the  dis- 
covery of  Frerlchs,  Kiihne,  and  others,  that  when  any  substance 
such  as  bile-acids  or  even  water,  which  has  the  property  of  dis- 
solving blood- corpuscles  and  liberating  haemoglobin,  is  injected 
into  the  veins,  bile-pigment  (bilirubin)  appears  in  the  urine  ;  and 
by  the  statement  of  Grehaut,  that  there  is  a  positive  destruc- 
tion of  haemoglobin  in  the  passage  of  blood  through  the  liver.* 
There  are,  on  the  other  hand,  grounds  for  believing  that  bile- 
pigment  is  in  its  turn  converted  into  urinary  pigment.^  A 
substance  presenting  spectroscopic  characters  similar  to  those 
of  urinary  pigment  can  be  prepared  by  deoxydation  from  bili- 
rubin ;  and  it  is  believed  that  in  the  organism  bile-pigments 
are  reduced  by  hydrogen  or  other  reducing  agents  present  in 
the  intestines.^  It  is  also  a  well-known  clinical  fact,  that 
nothing  influences  so  much  the  characters  of  the  urinary 
pigment  as  functional  or  structural  disease  of  the  liver.  The 
liver  then,  together  with  that  osmotic  circulation  constantly 
going  on  between  it,  the  blood,  and  the  contents  of  the  intestines, 
to  be  referred  to  presently,  appears  to  be  the  medium  of  conver- 
sion of  blood-pigment  into  bile-pigment,  and  of  bile-pigment 
into  urinary-pigment. 

The  bile-acids  in  human  bile  are  two — glycocholic  acid 
(C^^H^NO*^)  and  taurocholic  acid  (C-^H^^JNTO^S).  Both  acids  are 
derivatives  of  albumen  and  contain  nitrogen ;  and  taurocholic 
acid,  to  which  the  bitter  taste  of  bile  is  due,  contains  all  the 
sulphur  of  the  bile.  Both  are  in  bile  combined  with  soda,  and 
both  are  what  are  called  conjugate  acids  ;  that  is  to  say,  they 
are  composed  of  cholic  acid  (C-^H'^^O^),  which  contains  neither 

*  VirchoVs  Cellular  Pathology,  English  translation,  p.  1-14;  Kuhne,  LehrLuch  der 
Physiol,  Chemie,  Leipzig,  1S66,  p.  89. 

*  Jahrt:'sl).Ton  der  Gesellschaft  fiir  Natiir-und  Heil-kunde  in  Dresden,  1858,  p.  53. 
.3  Gaz  Med  de  Paris,  1859,  p.  469. 

*  Sanderson,  op.  cit.  p.  498. 

*  Bonce  Jones,  referred  to  by  G-.   Budd,  op.  cit.  p.  34 ;    Parkes,  On    the  Urme, 
1860,  p.  30. 

"  Sanderson,  op.  cit.  p.  499. 


544 


FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.       lect.  xiv. 


Bitrogen  nor  sulphur,  in  combination  with  taurin  (C^H^NO"*S), 
which  contains  both  nitrogen  and  sulphur,  and  gljcocin 
(C^H^NO^),  which  contains  nitrogen,  but  no  sulphur. 


Fig.  32.  Glj'cocholate  of  soda  from  ox  ujie  .nier  two  days'  crystallisation.  At  the 
lower  part  of  the  figure  the  crystals  are  melting  into  drops  from  the  evaporation  of 
the  ether  and  absorption  of  moisture.     After  J.  C.  Dalton. 


Fk!.  3^.  Glycocholate  and  taurocholate  of  soda  from  ox  bile  after  six  days'  crystal- 
lisation. The  glycoc-holate  is  crystallised;  the  taurocholate  is  in  fluid  drops.  After 
J.  C.  Dalton. 

Cholesterin  (C^°H'''*0)  is  a  fatty  substance,  which  crystallises 
in  colourless  rhombic  plates,  one  corner  of  which  is  often 
indented.  It  is  met  with  in  nerve-matter,  in  the  spleen,  in 
blood,  and  in  certain  morbid  exudations,  as  well  as  in  bile. 
An  American   physician,  Dr.  Austin  Flint,  jun.,  has  endea- 


M!CT.  XIV.  FUNCTIONS    OF    THE    LIVER    IN    HEALTH.  545 

voured  to  show  that  cholesterin  is  formed  for  the  most  part,  if 
not  entirely,  from  nerve-tissue,  from  which  it  is  taken  up  bjthe 
blood;  and  that  one  of  the  chief  functions  of  the  liver  is  to 
eliminate  this  cholesterin,  the  accumulation  of  which  in  the 


Fig.  34. — Crystalline  Plates  of  Cholesterin. 

blood,  from  the  liver  ceasing  to  act,  is  attended  by  cerebral  and 
other  symptoms  of  blood-poisoning.^ 

Bile  thus  constituted  is  being  constantly  secreted  by  the 
liver.  There  is  still  much  difference  of  opinion  as  to  the  part 
played  by  the  liver  in  the  formation  of  bile.  It  is  generally 
admitted  that  the  biliary  acids  are  formed  in  and  by  the  liver : 
but  many  physiologists  and  physicians  still  maintain  that  the 
bile-pigment  is  preformed  in  the  blood  and  is  merely  separated 
from  the  blood  by  the  liver  ;  and  they  explain  those  cases  of 
jaundice  in  which  there  is  no  obstruction  of  the  bile-duct,  by 
saying  that  bile-pigment  accumulates  in  the  blood  from  the 
liver  ceasing  to  act,  or  from  its  function  being  suppressed.^ 
But  it  has  long  appeared  to  me  that  there  are  weighty  objec- 
tions to  this  view.     (See  Lecture  IX.,  p.  327.) 

•Jt  -Jf  -x-  #  •*  -Jf  -Jf 

The  supposition  that  bile-pigment  is  formed  in  the  blood 
appears  to  me  for  these  reasons  to  be  untenable. 

The  quantity  of  bile  secreted  by  the  liver  has  been  shown 
experimentally  to  increase  suddenly  after  a  meal,  reach  its 
maximum  in  about  two  hours,  and  then  gradually  decline, 
while  by  abstinence  it  is  greatly  lessened.  In  considering  the 
functional  derangements  of  the  liver,  it  is  very  necessary  to 
remember  that  the  total  quantity  of  bile  secreted  in  twenty- 
four  hours  by  a  man  eating  an  ordinary  amount  of  food  is 
much  larger  than  might  be  expected  from  that  which  is  dis- 
charged from  the  bowel.     The  daily  quantity  of  human  bile  has 

'  Recherches  Exper.  sur  iine  nouvelle  fonction  du  Foie.     Paris,  1868. 
"^  Eudd,  op.  cit. ;  and  G.  Harley,  Jaundice,  its  Pathology  and  Treatment.     London, 
1863. 

N  N 


546  FUNCTIONAL   DEEANGEMEISTTS    OF    THE    LIVEE.      lect.  xiv. 

been  usually  calculated  from  what  has  been  observed  in  doo-s 
with  artificial  biliary  fistulse/  and  the  principal  results  have 
been  as  follow.  According  to  KoUiker  and  Miiller,  a  dog  con- 
suming daily  about  one-fifteenth  of  its  own  weight  of  meat 
secretes  in  twenty-four  hours  36'1  parts  of  fluid  bile  in  1,000 
parts  of  its  own  weight.  According  to  Dr.  George  Scott,  a  dog 
consuming  daily  about  one-fourteenth  of  its  own  weight  of 
meat  secretes  in  twenty -four  hours  28'13  parts  of  fluid  bile 
in  1,000  parts  of  its  own  weight.  According  to  Bidder  and 
Schmidt,  a  dog  consuming  daily  about  one-seventeenth  of  its 
own  weight  of  meat  secretes  in  twenty-four  hours  19'19  parts  of 
fluid  bile  in  1,000  parts  of  its  own  weight.  Making  allowance 
for  the  greater  relative  weight  of  the  liver  in  the  dog  than  in 
man,"^  it  follows  from  these  results  that  the  amount  of  fluid  bile 
secreted  in  twenty-four  hoars  by  a  man  weighing  160  lbs.  and 
on  full  diet,  is,  according  to 

Kolliker  and  Miiller       ....     66742  oz. 

Scott 42-763    „ 

Bidder  and  Schmidt       ....     35'476   „ 

Similar  experiments  have  been  made  on  dogs  by  Nasse, 
Platner,  and  Stackman,  and  from  their  data  Carpenter  has  cal- 
culated that  a  man  weighing  154  lbs.  should  secrete  daily 
about  40  oz.  of  bile.  It  may  be  assumed,  then,  from  experi- 
ments on  the  lower  animals,  that  the  quantity  of  bile  secreted 
in  twenty-four  hours  by  the  human  liver  is  about  40  oz. ;  and 
this  inference  is,  on  the  whole,  confirmed  by  what  is  observed 
in  those  rare  cases  where  a  biliary  fistula  discharging  bile  is 
produced  in  the  human  subject  by  ulcerative  perforation  of  the 
fundus  of  the  gall-bladder,  the  cystic  duct  remaining  patent, 
while  the  common  bile-duct  is  closed;  although  in  some 
instances  the  quantity  of  bile  has  been  less  than  in  health, 
from  the  patient  being  greatly  emaciated  and  taking  little 
food.  One  case  of  the  nature  referred  to  has  come  under 
my  own  notice,  the  particulars  of  which  are  worth  mentioning. 
Tlie  patient  was  a  lady  aged  40,  whom  I  saw  in  October 
18G9,  in  consultation  with  Mr.  Curling  (see  Case  CLXXII., 
p.  519).     Owing  to  an  obstruction  of  the  cystic  duct  by  a  gall- 

»  Oil  tills  sul)jeet.  sec  Bidder  and  Schmidt,  Die  Verdauungssafte  und  der  Stoif- 
Avichsel,  18.V2,  p.  186 ;  Dr.  G.  Scott,  Be.ile's  Archives  of  Medicine,  1858,  vol  i.  p.  218  ; 
Carpenter's  Human  Physiology,  7th  edit.  p.  144. 

2  The  weight  of  the  liver  of  the  dog  is,  from  six  ol)servations  of  Bidder  and 
Schmidt,  as  1  to  26  of  the  wliolo  body.  According  to  Quain,  the  weight  of  the  liver 
ill  man  is  as  1  to  36  of  the  whole  body. 


LECT.  XIV.  FUNCTIONS    OF    THE    LIVER   IN    HEALTH.  54/ 

stone,  the  gall-bladder  became  inflamed  and  converted  into  a 
chronic  abscess,  which  was  opened  externally.  A  fistulous 
opening  resulted,  which  discharged  a  scanty  colourless  viscid 
fluid  and  gave  exit  to  several  small  gall-stones.  But  after 
four  months,  with  a  fresh  attack  of  biliary  colic  and  vomit- 
ing, the  concretion  in  the  cystic  duct  Avas  dislodged  and 
projected  into  the  common  bile-duct,  which  it  obstructed,  as 
was  proved  by  the  motions  becoming  white  and  by  bile  being 
poured  in  large  quantity  through  the  fistulous  opening.  This 
state  of  matters  continued  for  forty-one  days  (the  patient  pass- 
ing white  stools,  but  having  scarcely  a  trace  of  jaundice),  when 
there  occurred  another  attack  of  biliary  colic  and  vomiting, 
during  which  the  concretion  escaped  into  the  duodenum  and 
the  flow  of  bile  was  restored  to  its  proper  channel.  In  this 
case,  the  quantity  of  bile  secreted  in  twenty-four  hours  was 
fully  two  pints,  although  the  patient  did  not  weigh  more  than 
about  130  lbs.  and  was  eating  but  a  moderate  diet.  I  have 
collected  several  other  cases  ^  of  a  similar  nature,  in  which  the 

'  Haller,  in  his  Phy>;iology,  alludes  to  the  case  of  a  man  with  a  biliary  fistula,  from 
■which  4  oz.  of  bile  escaped  in  six  hours  ;  but  there  is  no  mention  as  to  whether  or  not 
the  common  bile-duct  was  closed.     (Physiolo^ia  ;  Berne,  17fi4-,  tome  vi.  p.  605.) 

Heberden  (Commentaries,  4th  edit.  p.  210)  relates  the  case  of  a  woman  aged  50, 
who  discharged  '  a  great  quantity  of  yellow  fluid  for  the  space  of  four  years,'  from  a 
fistula  in  the  abdominal  wall. 

In  the  fourth  volume  of  the  Transactions  of  the  College  of  Physicians  Dr. 
Saunders  recorded  the  case  of  a  female  aged  66,  who  discharged  a  large  gall-stone 
through  the  abdominal  parietes.  For  three  weeks  afterwards  '  a  very  profuse  dis- 
charge of  bile  ran  perpetually  from  the  wound,'  although  the  common  bile-duct  re- 
mained pervious. 

In  tlie  twenty-seventh  volume  of  the  Medico-Chirurgical  Transactions,  Mr.  W.  R. 
Barlow  records  the  case  of  a  man  aged  54,  in  whom,  in  consequence  of  a  strain,  the 
common  bile-duct  became  temporarily  obstructed,  probably  by  a  gall-stone.  The  re- 
sult was,  that  in  twelve  days  thirteen  pints  of  fluid  accumulated  in  the  gall-bladder. 
Dr.  Owen  Rees  found,  on  analysis,  that  four-fifths  of  this  fluid  was  pure  bile,  so  that 
nearly  one  pint  of  bile  must  have  been  secreted  in  the  day,  althougli  the  patient  was  under 
the  antiphlogistic  treatment  of  the  day  (1844;,  and  had  been  repeatedly  bled  from 
the  arm  and  leeched.  Moreover,  as  there  was  no  external  fistula,  a  large  part  of  the 
secreted  bile  must  have  been  absorbed. 

In  the  thirty-fifth  volume  of  the  Medico-Chirurgical  Transactions  the  case  is  re- 
corded of  a  female  aged  64,  in  whom  the  daily  discharge  of  bile  from  a  fi>tula  was 
only  8  oz.  The  fistula  was  the  result  of  a  large  gall-stone  obstructing  the  common, 
bile-duct  and  existed  for  six  months,  at  the  en  1  of  which  time  the  woman  dieil 
from  exhaustion.  The  small  quantity  of  bile  in  this  case  was  accounted  for  by  the 
circumstance  of  the  patient  being  very  poor  and  having  insufficient  food. 

Dr.  J.  Hertz  of  Ivouigsberg  has  recorded  the  case  of  a  female  aged  28,  in 
whom  the  daily  flow  of  bile  from  a  biliary  fistula  was  18  fluid  oz.  It  is  doubtful, 
however,  if  all  the  bUe  secreted  was  really  discharged  from  the  fistula  ;  for,  though 
the  stools  were  of  a  pipe-clay  colour,  the  fact  that  the  flow  of  bile  into  the  bowel 

N  N  Z 


548  FUNCTIOlSrAL    DERANGEMENTS    OP    THE    LIVER.       lect.  xiv. 

results  more  or  less  corresponded  with  that  observed  in  my 
patient ;  but  I  will  not  occupy  time  in  reading  the  details.  T 
will  merely  mention  that  Fauconneau-Dufresne,  in  his  exhaus- 
tive memoir  upon  Biliary  Calculi  in  the  human  subject,  ob- 
serves that  from  external  biliary  fistulas,  to  which  they  now  and 
then  give  rise,  enormous  quantities  of  bile  may  be  discharged, 
so  as  to  inundate  the  patient.  He  mentions  one  case  in  which 
the  daily  amount  was  two  pints. ^ 

Moreover,  if,  as  seems  probable,  a  large  quantity  of  the  bile 
which  escapes  into  the  bowel  is  reabsorbed,  to  be  again  passed 
through  the  liver,  it  is  obvious  that  the  quantity  which  escapes 
from  a  biliary  fistula  after  closure  of  the  common  dnct,  in  a  dog 
or  in  man,  is  far  short  of  what  is  secreted  under  ordinary  cir- 
cumstances. This  inference  is  confirmed  by  the  experiments  of 
Schiff,  who  found  that  when  a  cannula  was  introduced  into  the 
gall-bladder,  after  closure  of  the  common  duct,  the  flow  of  bile 
was  never  so  great  as  it  was  immediately  after  the  operation, 
but  that  it  was  at  once  increased  when  bile  was  introduced  into 
the  veins  or  stomach.^ 

Although  the  amount  of  bile  secreted  daily  must  vary  in 
different  persons,  and  in  the  same  person  under  different  cir- 
cumstances, being  modified  by  the  quantity  and  quality  of  the 
food,  the  activity  of  respiration,  and  other  conditions,  it  is  clear, 
from  the  facts  now  mentioned  that  but  a  small  proportion  of 
what  is  ordinarily  secreted  is  discharged  from  the  bowel. 
Berzelins  found  in  1,000  parts  of  fresh  human  fseces  only  9 
parts  of  a  substance  similar  to  bile,  which,  on  the  calculation 
that  the  daily  fseces  of  a  man  weigh  5^  oz.,  would  make  a  total 
of  24  gr.  of  dried  bile  in  the  day.^  Now,  assuming  that  the 
liver  secretes  only  40  oz.  of  bile  in  the  day,  containing  only  5 
per  cent,  of  solid  matter,  which  is  considerably  below  the 
average  proportion,  the  amount  of  dried  bile  secreted  in  one  day 
would  be  960  gr.,  or  forty  times  the  quantity  discharged  from 
the  bowel.     According  to  Bischoif,  man  discharges  about  46  gr. 

was  restored  after  closure  of  the  external  opening  l)y  needles  (but  not  for  six  days, 
during  which  no  jaundice  appeared)  seems  to  show  that  the  oVistruction  of  the  common 
bile  duct  was  not  complete.     (Herliner  Klin.  Wochenschrift,  April  7,  1873.) 

Lastly,  Dr.  Joseph  Krumptmann  h:is  observed  the  case  of  a  man  who  at  64  got 
a  biliary  fistula  from  gall-stones,  which  for  ten  years  discharged  bi'e  up  to  half  a 
pint  daily.  When  the  man  died  at  74,  there  were  no  signs  of  impaired  nutrition,  so 
that  the  reporter  is  probably  justified  in  saying  that  only  about  one-fifth  of  the  total 
quantity  of  bile  secreted  escaped  by  the  fistula  (London  Med.  Rcc.  April  30,  1873). 

'   W'xn.  do  I'Acad.  Boyale  de  Med..  1847,  tome  xiii. 

»  Pflugers  Archiv,  1870,  p.  598.  ^  Budd.  op.  cit.  p.  52, 


LECT.  XIV.  FUNCTIONS    OP    THE    LIVER    IN    HEALTH.  ^  549 

of  the  (altered)  biliary  acids  by  the  fseces  per  diem  :  whilst 
Voit's  estimates  give  170  gr.  as  the  quantity  daily  formed 
by  the  liver;  124  gr.  therefore  must  be  otherwise  disposed 
of.^  Bidder  and  Schmidt  have  also  found  that  not  more  than 
one-eighth  of  the  sulphur  of  the  bile  is  normally  excreted  with 
the  faeces.^  The  bile-pigment  is  generally  believed  to  be  all 
voided  by  the  fseces ;  but  this  is  clearly  not  the  case  if  there 
be  any  truth  in  the  view  already  referred  to,  that  urinary  pig- 
ment is  formed  from  bile-pigment ;  while  the  fact,  familiar  to 
all  clinical  observers,  that  the  bile-pigment  discharged  from 
the  bowel  is  greatly  increased  by  calomel  and  other  aperients, 
without  any  corresponding  increase  of  secretion  by  the  liver, 
also  seems  to  show  that,  under  ordinary  circumstances,  much  of 
the  bile -pigment  secreted  by  the  liver  is  not  discharged  with 
the  fseces.  It  may  be  added  that  in  carnivorous  animals  and  in 
snakes,  altliough  bile-pigment  is  secreted  in  abundance  by  the 
liver,  the  quantity  discharged  with  the  fseces  is  even  relatively 
less  than  in  man.^ 

The  question  then  arises  as  to  what  becomes  of  the  bile 
which  is  not  discharged  from  the  bowel;  and  it  is  obviously 
one  having  an  important  bearing  on  the  pathology  of  many 
cases  of  jaundice,  as  well  as  upon  that  of  many  functional  de- 
rangements of  the  liver.  The  reply  is  to  be  found  in  the  fact, 
that  a  large  proportion  of  the  bile  secreted  by  the  liver  is  again 
absorbed,  either  by  the  biliary  passages,  or  by  the  mucous 
membrane  of  the  bowel.  From  what  is  now  known  of  the  diffu- 
sibility  of  fluids  through  animal  membranes,  it  is  impossible  to 
conceive  bile  long  in  contact  with  the  lining  membrane  of  the 
gall-bladder,  bile-ducts,  and  intestine,  without  a  large  portion 
of  it  passing  into  the  circulating  blood.  The  constant  secretion 
and  reabsorption  of  bile  is,  in  fact,  merely  part  of  that  osmotic 
circulation  constantly  taking  place  between  the  fluid  contents 
of  the  bowel  and  the  blood,  the  existence  of  which  is  too  little 


1  Carpenter's  Human  Physiology,  7th  edit.  p.  435. 

2  Die  Verdauungssafte  und  der  Stoffweehsel,  1852,  p.  218. 

'  Liebig  states  that  in  the  carnivora  the  whole  of  the  bile  is  reabsorbed  (Budd, 
op.  cit.  p.  61).  Todd  and  Bowman  also  state  that,  in  carnivorous  animals  'little  or 
no  bile  is  found  in  the  excrements ; '  and  'in  the  boa,  although  the  liver  is  large  and 
no  doubt  secretes  bile  freely,  the  excrements  contain  no  trace  of  bile'  (Physiology, 
vol.  ii.  p.  259).  Although  the  excrement  of  snakes,  after  feeding,  does  present  a 
brownish  colour  and  differs  from  the  white  masses  of  uric  acid  voided  at  other  times, 
Marcet,  who  is  an  authority  on  the  subject,  states  that  the  excrement  of  the  boa  is 
'  nearly  entirely  composed  of  urates.'     (Philosophical  Transactions,  1854,  p.  279.) 


550  FUNCTIONAL    DEEANGEMENTS    OF   THE    LIVEE.      lkct.  xiv. 

heeded  in  our  pathological  speculations^  and  in  therapeutics, 
although  attention  was  called  to  it  nineteen  years  ago  by  Dr. 
Parkes,  in  the  Gulstonian  Lectures  on  Pyrexia  delivered  before 
this  College.  '  It  is  now  known,'  says  Dr.  Parkes,^  '  that,  in 
Tai'yiiig  degrees,  there  is  a  constant  transit  of  fluid  from  the 
blood  into  the  alimentary  canal,  and  as  rapid  reabsorption. 
The  amount  thus  poured  out  and  absorbed  in  twenty-four 
hours  is  almost  incredible,  and  of  itself  constitutes  a  secondary 
or  intermediate  circulation  never  dreamt  of  by  Harvey.  The 
amount  of  gastric  juice  alone  passing  into  the  stomach  in  a  day, 
and  then  reabsorbed,  amounted  in  the  case  lately  examined  by 
Griinewald^  to  nearly  twenty-three  imperial  pints.  If  we  put 
it  at  twelve  pints,  we  shall  certainly  be  within  the  mark.  The 
pancreas,  according  to  Kroeger,  furnishes  twelve  pints  and  a  half 
in  t went}- four  hours,  while  the  salivary  glands  pour  out  at 
least  three  pints  in  the  same  time.  The  amount  of  the  bile  is 
probably  over  two  pints.  The  amount  given  out  by  the  intes- 
■  tinal  mucous  membrane  cannot  be  guessed  at,  but  must  be 
enormous.  Altogether  the  amount  of  fluid  effused  into  the  ali- 
mentary canal  in  twenty-four  hours  amounts  to  much  more  than 
the  whole  amount  of  blood  in  the  body ;  in  other  words,  every 
portion  of  the  blood  may,  and  possibly  does,  pass  several  times 
into  the  alimentary  canal  in  twenty-four  hours.  The  effect  of 
this  continual  outpouring  is  supposedto  be  to  aid  metamorphosis  ; 
the  same  substance,  more  or  less  changed,  seems  to  be  thrown 
out  and  reabsorbed,  until  it  be  adapted  for  the  repair  of  tissue 
or  become  effete.'  How  many  times  this  cycle  of  movement  is 
repeated,  before  the  bile  is  extruded  from  the  system,  we  have 
no  means  of  knowing;  but  in  the  course  of  this  osmotic  circu- 
lation, much  of  the  bile  appears  to  become  transformed  into 
products  which  are  eliminated  by  the  lungs  and  kidneys,  while 
at  the  same  time  this  circulation  assists  in  the  assimilation  of 
the  nutritive  materials  derived  from  the  food.^ 

'  The  purging  of  cholera  may  result  from  a  stoppage  of  tliis  intestinal  circulation 
• — a  diminished  power  of  absorption  rather  than  an  increased  exhahition  from  tlie 
bowel.  Many  facts  prove  that  in  cholera  the  power  of  absoi'ption  by  the  bowel  is 
greally  impaired  or  abolished. 

^  Medical  Times  and  Gazette,  1855,  vol.  i.  p.  333. 

'  An  account  of  this  case,  abstracted  by  me  from  Griinrwald's  I>atin  niemoii-,  Mill 
be  found  in  ]>eale's  Archives  of  Medicine,  vol.  i.  j).  270. — CM. 

*  It  may  be  thought  improbable  (hat  the  liver  should  secrete  from  the  blood  of 
the  portal  vein  materials  which  are  afterwiirds  to  be  absorljed  by  the  branches  of  Iho 
same  ve.ssel.  But  it  has,  perhaps,  been  too  readily  assumed,  from  the  comparatively 
large  size  of  the  vena  portte,  that  it  furnishes  the  materials  for  bile,     Allhougli,  when 


XECT.  XIV.  FUNCTIONS    OF    THE    LIVER    IN    HEALTH.  551 

In  the  first  place,  it  assists  in  tlie  absorption  of  fat.  It  is 
a  well-known  clinical  fact  that,  when  the  common  bile-duct 
becomes  obstructed  from  any  cause  in  man,  the  fat  throughout 
the  body  wastes.  Many  years  ago,  also,  it  was  shown  by  Drs. 
Bright  and  Owen  Rees  that,  in  cases  of  this  sort,  an  unusual 
quantity  of  fat  may  often  be  detected  in  the  stools.^  Bidder 
and  Schmidt  likewise  found  that,  after  applying  a  ligature  to 
the  gall-duct  of  a  dog,  the  animal  absorbed  less  fat  than  before, 
and  there  was  also  a  diminution  of  fatty  matter  in  the  chyle  in 
the  thoracic  duct ;  the  amount  absorbed  was  calculated  from  a 
comparison  of  the  fat  eaten  with  the  amount  passed  in  the 
fijeces.^  There  are  also  grounds  for  thinking  that  the  entrance 
of  bile  into  the  bowel  facilitates  the  absorption  of  the  albumin- 
ous constituents  of  the  food.  The  bile  neutralises  the  acid  that 
passes  from  the  stomach  into  the  duodenum,  and  in  doing  so 


one  vessel  is  diseased,  its  function  may,  in  part,  be  performed  by  the  other,  it  is  pro- 
bable that  under  ordinary  circumstances  the  portal  vein  ministers  chiefly  to  the 
assimilating  functions  of  the  liver,  transporting  to  it  the  nutriment  absorbed  by  its 
branches  from  the  stomach  and  bowels  ;  while  the  hepatic  artery  ministers  to  i^s  se- 
creting funcrion,  the  biliary  acids  and  bile-pigment  being  secreted  from  arterial 
blood,  like  urea  and  uric  acid,  which  in  the  kidneys  are  secreted  from  the  blood  of  the 
renal  artery.     This  view  is  based  on  such  facts  as  the  following  : — 

1.  In  the  Philosophical  Transactions  for  1793  a  case  is  recorded  whei-e  the  portal 
vein  passed  direct  to  the  vena  cava  inferior  without  entering  the  liver,  and  yet  bile 
"was  found  in  the  gall-bladder  and  intestines.  Similar  cases  are  referred  to  by  Dr. 
Carpenter.     (Principles  of  Human  Physiologj^  5th  edit.  p.  372.) 

2.  Many  cases  are  on  record  where  there  has  been  complete  obstruction  of  the 
portal  vein  from  disease  for  some  time  before  death,  and  yet  bile  has  continued  to  be 
secreted.  In  1856  Dr.  Gintrac  of  Bordeaux  collected  thirty-four  cases  of  obliteration 
of  the  portal  vein  in  man,  in  not  one  of  which  was  the  biliary  secretion  interrupted. 
(L'obliteration  de  la  veine  porte,  Bordeaux ;  see  also  Frerichs,  op.  cit.  vol.  i.  p.  274; 
and  Dickinson,  Pathological  Transactions,  vol.  xiv.  p.  63.) 

3.  In  animals  the  portal  vein  has  been  tied  by  Ore  and  other  experimenters,  and 
yet  bile  has  been  secreted.  The  reduction  in  the  quantity  may  have  been  due  to  the 
febrile  disturbance  created  by  the  operation,  or  to  the  absence  of  the  fatty  ingredients  of 
the  bile  which  may  be  contributed  by  the  portal  vein.  (Ore,  Journ.  d'Anat.  et  Phys., 
1864,  p.  556  ;  Carpenter's  Human  Physiology,  7th  edit.  p.  433  ;  and  Comparative 
Physiology,  4th  edit.  p.  424.) 

4.  Conversely,  Kottmeier  and  Kiithe  found  that  no  bile  was  secreted  after  ligature 
of  the  hepatic  artery,  although  it  is  right  to  add  that  Schifif  was  unable  to  detect  any 
diminution  in  a  large  dog,  upon  which  he  had  performed  the  same  operation ;  and 
Pohrig  observed  only  a  slight  diminution  in  the  flow  of  bile  after  obstruction  of  the 
hepatic  artery.  (Carpenter,  Human  Physiology,  7th  edit.  p.  433;  and  Kuhrig,  in 
Strieker's  Jahrb.  1873,  part  ii.) 

5.  Portal  blood  contains  very  little  cholesterin,  but  that  of  the  hepatic  artery  con- 
tains a  large  quantity.     (Trousseau,  Clin.  Lect.  Syd.  Soc.  Ed.  v.  140.) 

'  Guy's  Hospital  Eeports,  series  i.  vol.  i.  p.  610, 
^  Sanderson,  op.  cit.  p.  505, 


552  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.      lect.  xiv. 

causes  a  precipitate  of  peptone.  It  is  difficult  to  say  what 
purpose  is  served  by  this  precipitation ;  but  some  experiments 
of  Bernard  led  him  to  the  conclusion  that  gastric  juice,  when 
mixed  with  pancreatic  juice  and  bile,  has  a  more  solvent  action 
on  albuminous  substances  than  the  gastric  juice  alone. ^  The 
passage  of  bile  into  the  bowel  appears  also  to  be  in  some  way 
essential  to  the  formation  of  glycogen  by  the  liver.  In  a 
number  of  experiments  recently  made  upon  cats,  Dr.  Wickham 
Legg  found  that  the  formation  of  glycogen  was  always  arrested 
soon  after  ligature  of  the  bile-duct ;  in  one  cat  the  diabetic 
puncture  of  the  brain  was  made  on  the  sixth  day  after  ligature 
of  the  bile-ducts,  but  no  sugar  appeared  in  the  urine. ^  The 
production  of  urea,  however,  in  the  liver  appears  to  be  quite 
independent  of  the  passage  of  bile  into  the  bowel,  for  in  cases 
of  permanent  obstruction  of  the  galhduct  the  amount  of  urea 
voided  in  the  urine  may  be  quite  normal. 

But,  lastly,  there  can  be  no  doubt  that  bile  is  in  part  excre- 
mentitious,  a  portion  of  it  being  discharged  from  the  bowel, 
and  serving  to  rid  the  system  of  some  of  the  products  of  waste 
of  the  blood  and  tissues.  The  biliary  acid  salts  are  decomposed, 
and,  by  their  decompositioDi,  they  furnish  the  free  alkali  neces- 
saiy  for  the  precipitation  of  peptones  and  the  saponification  of 
the  fatty  matters  ;  they  are  believed  also  to  become  further 
split  up,  the  taurin,  glycocin,  and  most  of  the  cholic  acid 
returning  to  the  circulation,  while  a  portion  of  the  cholic  acid 
is  discharged  with  the  fseces.  The  cholesterin  is  also  decom- 
posed in  the  bowels,  and  the  products  of  its  decomposition  are 
discharged  with  the  fseces.  According  to  Dr.  Austin  Mint, 
jun.,  the  cholesterin  is  converted  into  a  substance  which  he  has 
discovered  in  the  faeces  and  designated  stercorin ;  it  appears 
also  to  be  in  some  way  related  to  another  ingredient  of  the 
fseces  discovered  by  Marcet  and  called  excretin,  although  this 
contains  sulphur.  Marcet,  at  all  events,  made  ihe  observation, 
that  in  very  young  children  cholesterin  may  take  the  place  of 
excretin  in  the  stools.^  The  bile-pigment  also  becomes  changed 
in  its  passage  through  the  bowel,  the  bilirubin  becoming  con- 
verted into  biliverdin.  Lastly,  the  bile,  in  its  passage  through 
the  bowel,  stimulates  the  peristaltic  action  of  the  gut ;  and,  in 

'  Eu<](l,  (jp.  cit..,  p.  !)0. 

^  On  the  Gliiinges  in  the  Liver  which  follow  Ligature  of  the  Bile-ducts.     (St. 
Bartholomew's  Hospital  Reports,  vol.  ix.  1873.) 

'  Jourjuil  of  tlio  Chemical  Society,  October  and  November  1862. 


lECT.  XIV.  CLASSIFICATION.  553 

virtue  of  its  antiseptic  property,  which  can  be  demonstrated  out 
of  the  body,  it  prevents  putrefactive  fermentation  of  the  in- 
testinal contents  and  the  excessive  generation  of  gas. 

From  what  has  been  stated,  it  follows  that  the  functions  of 
the  liver  may  be  summed  up  under  three  heads,  viz.  : — 

1.  The  formation  of  glycogen,  which  contributes  to  the 
maintenance  of  animal  heat  and  to  the  nutrition  of  the  blood 
and  tissues  ;  and  the  development  of  white  blood-corpuscles. 

2.  The  destructive  metamorphosis  of  albuminoid  matter, 
and  the  formation  of  urea  and  other  nitrogenous  products, 
which  are  subsequently  eliminated  by  the  kidneys,  these 
chemical  changes  also  contributing  to  the  develoj^ment  of 
animal  heat. 

3.  The  secretion  of  bile,  the  greater  part  of  which  is  re- 
absorbed, assisting  in  the  assimilation  of  fat  and  peptones  and 
probably  in  those  chemical  changes  which  go  on  in  the  liver 
and  portal  circulation  :  while  part  is  excrementitious,  and,  in 
passing  along  the  bowel,  stimulates  peristalsis  and  arrests 
decomposition. 

B.    FUNCTIONAL    DERANGEMENTS    OF    THE    LIVEE. 

Keeping  in  view  the  functions  of  the  liver  in  health,  which 
I  have  endeavoured  thus  briefly  to  sketch,  we  shall  be  the  better 
able  to  discuss  the  symptoms  resulting  from  derangements  of 
these  functions.  The  few  medical  writers  who  have  described 
the  functional  derangements  of  the  liver  have,  like  the  late  Dr. 
Copland,'  arranged  them  under  the  three  following  heads  :  1. 
Diminished  secretion  of  bile ;  2.  Increased  secretion  of  bile ; 
3.  Secretion  of  morbid  or  altered  bile.  But  this  classification 
fails  fco  recognise  the  most  important  functions  of  the  liver ;  and, 
from  what  has  been  stated,  it  follows  that  the  quantity  and 
quality  of  the  bile  discharged  from  the  bowel,  upon  which  the 
classification  is  based,  are  no  certain  tests  of  the  amount  and 
quality  of  the  bile  secreted  by  the  liver.  The  quantity  secreted 
being  the  same,  the  quantity  discharged  from  the  i)owel  will 
vary  with  whatever  stimulates  or  impedes  absorption.  Any 
substance  like  calomel,  or  podophyllin,  or  certain  articles  of  diet, 
which  irritates  the  commencement  of  the  small  intestine,  will 
sweep  along  the  bile  before  there  is  time  for  its  absorption, 
and  thus  cause  an  increased  flow  from  the  bowel,  without  the 

'  3Iedical  Dictionary,  vol.  ii.  p.  723. 


554  FUNCTIONAL    DERANGEMENTS    OP    THE    LIVEE.      lect.  xiv. 

secretion  by  tJie  liver  being  necessarily  increased.  Moreover,  it 
must  often  be  impossible  to  say  whetlier  the  morbid  or  altered 
appearances  of  the  bile  in  the  fseces  be  due  to  a  vitiated  bile,  or 
to  changes  which  the  bile  has  undergone  in  its  passage  through 
the  bowel.  For  these  reasons,  I  have  ventured  to  suggest 
another  classification  of  the  functional  derangements  of  the 
liver,  based  upon  what  are  now  believed  to  be  the  normal  func- 
tions of  the  gland,  and  upon  the  symptoms  which  a  disordered 
liver  may  excite  in  the  different  physiological  systems  of  the 
body. 

Classification  of  the  Functional  Derangements  of  the  Liver. 

I.  Abnormal  Nutrition. 
II.  Abnormal  Elimination. 

III.  Abnormal  Disintegration. 

IV.  Derangements  of  the  Organs  of  Digestion. 
V.  Derangements  of  the  Nervous  System. 

VI.  Derangements  of  the  Organs  of  Circulation. 
VII.  Derangements  of  the  Organs  of  Respiration. 
VIII.  Derangements  of  the  Genito-Urinary  Organs. 
IX.  Abnormal  Conditions  of  the  Skin. 

I.  Abnormal  Nutrition. 

Functional  derangement  of  the  liver  may  lead  directly  to 
(1)  an  abnormal  deposition  of  fat,  or  to  (2)  the  opposite  condi- 
tion of  emaciaticm.  Indirectly,  also,  the  nutrition  of  the  body 
may  become  seriousl}^  impaired  from  derangements  of  the  dis- 
integrative functions  of  the  liver. 

1.  Corpulence,  by  which  so  many  persons  are  inconvenienced, 
owes  its  origin  to  difiPerent  causes.  We  know  that  it  is  very 
liable  to  occur  in  persons  who  eat  much  fat  and  take  little 
exercise.  In  this  case,  the  lacteals  absorb  more  fat  from  the 
bowel  than  is  sufficient  to  supply  the  carbon  consumed  in  respi- 
ration, or  there  is  a  deficient  consumption  of  fat  in  the  system. 
Many  facts,  however,  show  clearly  that  the  accumulation  of  fat 
is  not  due  solel}'  to  an  increased  supply  of  fatty  matter  in  the 
food  and  its  absorption  by  the  lacteals.  Thus,  of  two  persons 
consuming  the  same  amount  of  fat  and  taking  the  same  amomit 
of  exercise,  one  will  accumulate  fat  and  the  other  will  not ;  and 
in  many  persons  the  accumulation  of  fat  appears  to  be  one  of 
the  characteristics  of  old  age,  just  as  other  persons  in  growing 


r.ECT.  XIV.  ABNORMAL    NUTRITIOlSr.  555 

old  wither  and  dry  up.  Again,  some  i^ersons,  witli  every  care 
as  to  diet,  cannot  avoid  getting  fat ;  while  others,  consuming 
much  fat,  as  well  as  saccharine  and  starchy  matter,  remain 
permanently  thin.  And,  thirdly,  it  is  a  fact  established  by 
many  observations  both  in  man  and  in  the  lower  animals,  that 
fat  is  formed  in  large  quantity  from  a  diet  containing  much 
starch  and  sugar,  and,  from  what  has  already  been  stated,  it 
seems  probable  that  the  liver  is  mainly  concerned  in  this  trans- 
formation. Some  of  the  fattest  persons  I  have  met  with  have 
been  females,  who  have  for  a  long  time  eaten  little  or  no  fat  or 
oily  matter,  and  who  indeed  have  taken  very  little  solid  food, 
but  who  have  contracted  the  habit  of  drinking  frequently  some 
mixture  of  alcohol  and  sugar,  such  as  we  find  in  beer,  cham- 
pagne, and  other  wines,  and  who  at  the  same  time  have  taken 
little  exercise  and  have  suffered  from  symptoms  of  deranged 
liver.  M.  Dancel  relates  the  case  of  a  young  lady,  who,  finding 
herself  getting  stout,  and  with  the  object  of  preserving  her 
symmetry,  fasted,  as  she  thought,  four  days  in  the  week  upon 
champagne  and  marrons  glaces ;  but  with  this  diet  she  accu- 
mulated fat  with  frightful  rapidity,  and  it  was  only  after  return- 
ing to  a  more  rational  diet  that  she  regained  her  normal  figure.' 
The  tendency  to  accumulate  fat,  or  the  reverse,  appears  to  be 
due  to  some  constitutional  ]3eculiarity  transmissible  by  parents 
to  their  offspring;  and,  from  what  we  know  of  the  functions  of 
the  liver,  it  is  highly  probable  that  this  is  the  organ  mainly  at 
fault.  Possibly,  there  may  be  an  abnormal  proneness,  or  the 
reverse,  to  the  conversion  of  glycogen  into  fat,  in  the  manner 
suggested  by  Dr.  Pavy;  or,  from  some  derangement  of  the 
liver,  a  larger  proportion  of  the  glucose  derived  from  the  food 
may  be  directly  converted  into  fat  than  in  health  ;  or,  in  some 
instances,  obesity  may  be  due  to  a  deficient  oxydation  of  fatty 
matter.  Although  we  can  only  as  yet  speculate  as  to  the 
precise  nature  of  the  morbid  process,  we  know  that  in  animals 
eating  much  farinaceous,  saccharine,  or  oleaginous  food,  the 
proportion  of  fatty  particles  in  the  secreting  cells  of  the  liver 
is  much  greater  than  in  animals  moderately  fed  and  taking 
much  exercise. 

Persons  of  a  corpulent  tendency  are  very  liable  to  flatulence, 
constipation,  heaviness  and  weariness  after  meals,  and    other 

'  Quoted  by  Dr.  T.  K.  Chambers  (Clinical  Lectures,  1864,  p.  o47).  I  have  failed 
to  find  the  case  in  the  Traite  Theorique  at  Pratique  de  I'Obesite,  par  I'.  Uaucel ; 
Paris,  1863. 


556  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVEE.       lect.  xiv. 

symptoms  of  hepatic  derangement.  After  a  time,  they  lose  all 
appetite  for  solid  food  ;  they  complain  of  great  prostration  and 
of  sensations  of  sinking,  which  prevent  their  making  much 
muscular  exertion  and  often  encourage  them  in  habits  of 
tippling. 

Lastly,  by  improving  the  condition  of  the  liver  not  only 
these  symptoms,  but  the  corpulence,  will  often  disappear. 

2.  Emaciation  may  be  induced  by  functional  derangement 
of  the  liver  in  diflPerent  ways. 

a.  In  consequence  of  a  deficient  formation  of  bile,  or  of  its 
impeded  passage  into  the  bowel,  the  assimilation  of  fatty  and 
albuminous  matters  is  interfered  with.  It  is  true  that  cases  are 
occasionally  met  with  in  which  the  common  gal] -duct  has  been 
completely  and  permanently  closed  by  a  gall-stone,  so  that  no 
bile  could  flow  into  the  intestine,  and  yet  the  body  has  been 
tolerably  well  nourished  even  after  two  or  three  years.'  There  are, 
however,  few  exceptions  to  the  rule,  that  permanent  closure  of 
the  common  bile-duct  destroys  life  in  the  end — usually  in  little 
more  than  twelve  months,  if  not  before — by  causing  a  gradual 
impairment  of  nutrition.  Most  patients  with  obstruction  of  the 
bile-duct  dislike  fat  and  cannot  assimilate  it,  the  fatty  matters 
of  the  ingesta  being,  as  already  stated,  discharged  with  the 
faeces.  There  are  also  reasons  for  thinking  that  the  absence  of 
bile  from  the  bowel  interferes  with  the  absorption  of  peptones  ; 
while  Dr.  Legg's  observation  that  ligature  of  the  hepatic  duct 
in  animals  arrests  the  glycogenic  function  of  the  liver  makes 
it  probable  that,  when  the  flow  of  bile  into  the  bowel  is  iDipeded, 
the  nutrition  of  the  bod}^  suffers  in  other  ways  than  by  the 
deficient  absorption  of  fat  and  albumen.  Obstruction  of  the 
bile-ducts  also  leads  to  a  deficient  formation  of  blood-corpuscles 
and  anaemia.  A  deficient  secretion  or  a  morbid  quality  of  bile 
may  possibly  lead  to  similar  results,  though  in  a  less  degree. 

b.  But,  secondly,  emaciation  may  result  from  derangement 
of  the  glycogenic  function  of  the  liver.  Diabetes,  in  fact,  may 
be  said  to  be  'in  most  instances  a  derangement  of  the  glycogenic 
function  of  the  liver.  It  would  be  out  of  place  here  to  consider 
in  detail  what  are  now  believed  to  be  the  various  causes  of 
glycosuria  ;  ^  but,  briefly,  they  may  be  said  to  come  under  one 
of  the  three  following  heads. 

'  Endfl,  op.  cit.  p.  49. 

^  These  arc  well  given l)y  Dr.  T.  L.  Erunton  in  his  Lectures  in  the  British  Medical 
Journal  fur  .Jjumary  and  February  1874. 


LECT.  XIV.  ABNORMAL    NUTEITIOlSr.  55/ 

1.  Imperfect  glycocjenesis  in  the  liver.  One  function  of  the 
liver  in  health  appears  to  be  to  prevent  the  immediate  passajj-e 
into  the  blood  of  the  glucose  derived  from  the  food,  bj  converting' 
it  into  glycogen.  Thus,  Bernard  has  shown  that,  if  a  ligature 
be  applied  to  the  portal  vein  in  an  animal,  so  that  the  intestinal 
blood,  rich  in  glucose,  reaches  the  systemic  circulation  without 
passing  through  the  liver,  sugar  at  once  appears  in  large  quan- 
tity in  the  urine ;  and  in  man  diabetes  has  been  known  to 
occur  when  the  portal  vein  has  been  obliterated.^  Again,  if 
sugar  be  injected  into  the  crural  vein  or  into  the  rectum,  it 
appears  in  the  urine ;  but,  if  it  be  injected  slowly  into  the 
portal  vein,  the  urine  will  contain  none.^  The  capability  of  the 
liver  to  convert  sugar  into  glycogen  is  not  unlimited.  When, 
therefore,  sugar  is  swallowed  in  excess  of  a  certain  quantity,  it 
appears  in  the  urine  ;  and  the  same  thing  happens  when  much 
sugar  or  starch  is  taken  after  long  fasting,  owing  to  the 
rapidity  of  intestinal  absorption  ;  or  when,  in  consequence  of 
disease,  old  age,  injury  of  the  liver,  unsuitable  food,  or  some 
other  cause,  the  glycogenic  function  of  the  liver  is  impaired. 
Glycosuria,  often  temporary,  from  some  of  these  causes  is  not 
uncommon.  According  to  Bence  Jones,  in  half  of  the  cases  of 
diabetes,  the  disease  "consists  in  an  arrest  of  change  in  the  food- 
sugar. 

2.  An  increased  conversion  of  glycogen  into  sugar,  the  destruc- 
tion of  the  sugar  remaining  unaltered.  This  appears  to  be  the 
main  cause  of  persistent  glycosuria,  or  diabetes.  In  considering 
the  functions  of  the  liver,  it  was  pointed  out  that  the  glycogen 
formed  in  it  was  partly  converted  into  sugar,  which  disappeared 
in  the  lungs  and  muscles,  but  was  probably  mainly  destined  to 
support  the  nutrition  of  the  blood  and  tissues  throughout  the 
body.  Whatever,  then,  favours  the  flow  of  sugar  from  the  liver 
into  the  blood,  to  an  extent  greater  than  can  be  consumed  in 
the  lungs  and  muscles,  will  lead  to  au  excess  of  sugar  in  the 
blood  and  its  appearance  in  the  urine,  and  will  to  a  correspond- 
ing extent  interfere  with  the  nutrition  of  the  body.  Now 
whatever  quickens  the  circulation  of  blood  through  the  liver 
particularly  in  the  hepatic  arteries,  favours  the  conversion  of 
glycogen   into  sugar,   possibly   by  increasing  the   amount  of 

•  See  abstract  of  Lectures  in  London  Medical  Record  for  October  and  November 
1873. 

-  Pavj',  Nature  and  Treatment  of  Diabetes,  2nd  edit.  1869,  pp.  142-43  ;  and  Bence 
Jones,  Lectures  on  Pathology  and  Therapeutics,  1867,  p.  42. 


558  FUISrCTIO]SrAL    derangements    of    the    liver.      lect.  XIV. 

albuminoid  ferment  already  referred  to ;  and  accordingly, 
whatever  paralyses  the  vaso-motor  nerves  of  the  hepatic  vessels, 
either  directly  or  indirectly,  dilates  these  vessels,  produces  an 
increased  flov^  of  blood  through  them,  and  so  leads  to  diabetes. 
The  tendency  of  glycogen  to  become  converted  into  sugar 
appears  to  be  moderated  in  health  by  some  nervous  influence,  on 
the  removal  of  wrhich  the  blood  becomes  surcharged  with  sngar 
which  enters  the  urine.  The  recent  observations  of  Dr.  Pavy  ^ 
show  also  that  oxygenated  blood  in  some  manner  influences  the 
liver  so  as  to  lead  to  the  production  of  glycosuria,  which  is 
accordingly  induced  when  blood  reaches  the  portal  system 
without  having  become  dearterialised  in  the  natural  way, 
owing  to  vaso-motor  paralysis  of  the  vessels  of  the  chylo-poietic 
viscera.  Thus  it  is  that  diabetes  is  produced  by  irritatit-n  of 
the  roots  of  the  pneumogastric  nerve  in  Bernard's  '  diabetic 
puncture,'  by  certain  injuries  and  diseases  of  the  brain  and 
spinal  cord  in  man,  by  distress  and  anxiety  of  mind,  by  poison- 
ing with  woorari,  and  by  injuries  or  lesions  of  the  peripheral 
extremities  of  the  pneumogastric  nerve  in  the  lungs,  liver, 
stomach,  or  intestines. 

3.  Diminished  destruction  of  sugar.  If  the  sugar  into  which 
the  glycogen  formed  in  the  liver  is  converted  did  not  disappear 
from  the  blood,  it  would  necessarily  form  one  of  the  normal 
constituents  of  the  urine.  Hence  it  cannot  be  denied  that  the 
pathological  presence  of  sugar  in  the  urine  may  possibly  depend 
in  some  cases  upon  a  failure  of  the  conditions  under  which  the 
normal  transformation  of  the  sugar  takes  place.  We  are, 
however,  in  great  measure  ignorant  as  to  what  these  condi- 
tions are.  A  number  of  experiments  make  it  probable  that  the 
sugar  in  the  blood,  under  the  influence  of  a  ferment,  is  converted 
into  lactic  acid  and  glycerin,  which  undergo  combustion  and  so 
maintain  the  animal  heat;  and  it  is  believed  that,  when  this 
ferment  is  absent,  the  sugar  is  not  decomposed,  but  is  excreted 
in  the  urine.  Whether  this  be  the  true  explanation  or  not, 
many  facts  seem  to  show  that  glycosuria  may  result  from  a 
morbid  state  of  the  blood.  Thus  the  introduction  into  the 
blood  of  ammonia,  ether,  chloroform,  or  iDhosphoric  acid  is 
followed  by  glycosuria  ;  while  the  introduction  of  carbonate  of 
soda  will  prevent  it.  Glycosuria  also  has  been  repeatedly  ob- 
served in  cases  of  pneumonia,  whooping-cough,  and  phthisis, 
which  lead  to  deficient  oxygenation  of  the  blood.  It  is  worth 
'  Proc.  Roy.  Soc.  Nos,  163,  164.  1875. 


LECT.  XIV.  ABNORMAL    ELIMINATION.  559 

adding  that  there  has  long  been  supposed  to  be  an  antagonism 
between  diabetes  and  gout.  Gouty  dyspepsia  and  actual  gout 
have  been  observed,  to  cease  on  the  supervention  of  diabetes  ; 
and  it  was  pointed  out  by  Sir  C.  Scudamore  that  the  Scotch 
were  much  more  liable  to  diabetes,  and.  less  prone  to  gout,  than 
the  inhabitants  of  England. 

c  It  is  not  improbable  that  other  wasting  diseases  are  in 
their  origin  connected  with  some  functional  disorder  of  the 
liver.  When  there  is  derangement  of  the  disintegrative 
function  of  the  liver,  the  blood  and  fluid  effused  from  it  become 
loaded  with  effete  matter,  as  the  result  of  which  the  nutri- 
tion of  the  tissues  is  often  impaired  and  the  body  wastes.  In 
phthisis,  again,  long  before  tubercle  is  deposited  in  the  lungs, 
there  is  evidence  of  deficient  assimilation  of  nutriment  and  im- 
perfect sanguification — functions  in  which  we  know  that  the 
liver  is  deeply  concerned.  Again,  the  protracted  purulent 
discharge  which  usually  precedes  waxy  disease  may  entail  a 
hasty  and  imperfect  sanguification,  resulting  in  angemia  and 
the  formation  of  an  albuminous  material  little  capable  of  or- 
ganisation. 

II.  Abnormal  Elimination. 

In  discussing  the  functions  of  the  liver,  I  stated  that  bile  is, 
in  part,  excrementitious,  although  this  is  probably  far  from 
being  its  chief  use  in  the  economy  of  digestion.  In  accordance 
with  the  belief  still  held  by  many  members  of  the  profession 
engaged  in  practice,  that  the  chief  function  of  the  liver  is  to 
excrete  bile,  the  retention  of  bile  in  the  blood  and  tissues  is 
believed  to  give  rise  to  serious  symptoms.  For  example,  when 
such  symptoms  as  delirium,  stupor,  muscular  tremors,  subsultus, 
carphology,  paralysis  of  the  sphincters,  coma,  convulsions,  a  dry 
brown  tongue,  and  other  phenomena  of  the  '  typhoid  state  ' 
supervene  in  any  case  of  jaundice,  in  acute  atrophy  of  the  liver, 
or  in  the  advanced  stage  of  cirrhosis,  it  is  customary  to  attri- 
bute them  to  poisoning  of  the  blood  with  retained  bile.  Ex- 
periments, also,  have  been  performed  on  animals,  with  the 
object  of  showing  that  bile  is  a  deadly  poison.  But  that  dogs 
should  die  after  injection  into  the  cellular  tissue  of  the  bile 
of  other  dogs  admits  of  another  explanation  than  that  of  the 
essential  elements  of  bile  being  a  poison.  The  injection  of 
decomposing  mucus  would  probably  produce  a  lilce  result.  Pure 
bile,  from  which  all  mucus  has  been  removed,  has  been  repeatedly 


560  FUNCTIONAL    DERANGEMENTS    OP    THE    LIVER.       lect.  xiv. 

injected  into  the  large  veins  of  dogs  by  Frericlis  and  other 
observers,  without  any  cerebral  symptoms  or  bad  results  ensuing, 
except  that  in  some  instances  death  has  been  caused  by  the 
entrance  of  air  into  the  veins.^  The  operation  has  even  been 
repeatedly  performed  on  the  same  animal  without  any  lasting 
injury;  but  it  is  scarcely  necessary  to  have  recourse  to  experi- 
mental researches  on  the  lower  animals  for  evidence  on  the 
matter,  and  in  all  these  experiments  there  are  sources  of  fallacy. 
Every  medical  practitioner  must  be  familiar  with  the  fact,  that 
the  blood  and  tissues  of  man  may  be  saturated  with  bile  for 
months,  without  cerebral  or  any  other  symptoms  of  blood- 
poisoning  resulting,  so  long  as  the  glandular  tissue  of  the  liver 
is  not  destroyed  and  the  kidneys  continue  to  perform  their 
functions.  Bearing  such  cases  in  mind,  it  is  difficult  to  believe 
that  bile  is  a  deadly  poison. 

Reference  has  already  been  made  to  the  views  of  an  Ameri- 
can physiologist.  Dr.  Austin  Flint,  jun.,  who  has  wi'itten  a 
work  to  show  that  the  cerebral  symptoms  which  occasionally 
occur  in  jaundice  and  in  structural  diseases  of  the  liver  are  due 
to  the  retention  in  the  blood  of  cholesterin,  or  to  what  he  has 
designated  '  Gholestearcemia.'  ^  Dr.  Flint  regards  cholesterin  as 
an  excrementitious  product  of  nervous  tissue,  the  elimination 
of  which  from  the  body  he  believes  to  be  one  of  the  functions 
of  the  liver.  Having  arrived  in  the  bowel,  the  cholesterin,  ac- 
cording to  him,  is  converted  into  stercorin,  and  therefore  it  is 
not  found  in  the  fgeces  ;  but  when  retained  in  the  blood  and 
tissues,  he  believes  it  to  be  a  virulent  poison  like  urea.  But  if 
the  non-excretion  of  all  the  elements  of  bile  do  not  give  rise 
to  cerebral  symptoms,  it  is  difficult  to  understand  how  these 
symptoms  can  result  from  the  retention  of  cholesterin  alone. 
In  cases,  for  instance,  of  permanent  closure  of  the  bile-duct, 
cholesterin  is  not  discharged  from  the  liver  into  the  bowel ;  it 
does  not  accumulate  in  the  biliary  passages;  nor,  if  it  be  present 
in  the  blood,  does  it  necessarily  give  rise  to  cerebral  symptoms. 

From  what  has  been  stated,  I  think  it  must  be  clear  that 
the  cerebral  symptoms  which  occasionally  supervene  in  certain 
morbid  states  of  the  liver  are  independent  of  the  non-excretion 
of  bile,  or  of  any  of  its  component  parts.  The  real  cause  of 
these  cerebral  symptoms  will  be  referred  to  hereafter. 

The  symptoms  usually  associated  with  a  deficient  excretion 
of  bile  are  an  irregular,  usually  costive,  state  of  the  bowels,  the 

'  Diseases  of  Liver,  SyJenham  Society's  translation,  vol.  i.  p.  395.  *  Op.  cit. 


TECT.  xiT.  ABNCRMAIl  ELIMINATIOIf.  56 1 

stools  being  insuflficiently  coloured  with  bile  and  of  a  pale  yellow, 
drab,  or  whitish  colour ;  loss  of  apj^etite  ;  a  white  or  yellowish 
furred  tongue ;  a  disagreeable,  often  bitter,  taste  in  the  mouth, 
especially  in  the  morning ;  flatulence ;  a  sallow  or  muddy  tint 
of  skin  (indicating,  unless  there  be  concurrent  hypersemia  of 
the  liver,  anremia  rather  than  jaundice)  ;  dingy  conjunctivae  ; 
languor  and  disinclination  for  exertion  ;  frontal  headache ;  dul- 
ness  and  heaviness,  drowsiness  after  meals,  great  depression  of 
spirits,  and  sometimes  hypochondriasis ;  and  frequent  deposits 
of  lithates  in  the  urine  on  cooling.  These  symptoms  are  very 
apt  to  be  induced,  especially  towards  middle  life,  by  sedentarj 
or  indolent  habits,  the  habitual  use  of  rich  or  indigestible  food, 
neglect  of  the  bowels,  great  or  protracted  anxiety  of  mind,  or 
by  a  general  want  of  vigour,  consequent  upon  disease  of  the 
heart  or  of  some  other  organ;  and  the  tendency  to  them  is 
in  many  cases  inherited.  They  are  commonly,,  and  perhaps 
correctly,  ascribed  to  what  is  called  '  tori3or  of  the  liver ; '  but 
the  non-excretion  of  bile  may  possibly  be  merely  one  of  the 
symptoms,  rather  than  the  cause,  of  the  morbid  state,  the  real 
cause  being  the  retention  in  the  system,  not  of  bile,  but  of  those 
products  of  disintegration  which  it  is  the  purpose  of  the 
kidneys  to  eliminate.  At  the  same  time,  it  is  very  probable 
that  engorgement  of  the  liver  with  bile  interferes  with  the 
normal  proee-jses  of  disintegration  of  albumen  which  take  placo 
in  the  gland. 


0  o 


562  FUNCTIONAL    DERANGEMENTS    OP    THE    LIVER. 


LECTUEE   XV. 

THE  CROOXIAN  LECTURES  ON  FUNCTIONAL  DERANGE- 
MENTS OF  THE  LIVER. 

m.  ABNORMAL  DISINTEGRATION.  1.  lITHiEMIA  ;  2.  GOUT  ;  3.  UEIN\RY  CALCULI  ;  4. 
BILIARY  CALCULI  ;  5.  DEGENERATIONS  OF  THE  KIDNEYS  AND  ALBUMINURIA  ;  6. 
STRUCTURAL  DISEASES  OF  THE  LIVER  ;  7.  DEGENERATIONS  OF  TISSUE  THROUGHOUT 
BODY  ;  8.  LOCAL  INFLAMMATIONS  ;  9.  '  CONSTITUTIONAL  DISEASES.' IV.  DERANGE- 
MENTS OF  ORGANS  OF  DIGESTION.  1.  TONGUE;  2.  APPETITE;  3.  TASTE;  4.  DYS- 
PEPSIA ;  5.  CONSTIPATION  AND  DIARRHOEA  ;  6.  VITIATED  STOOLS  ;  7.  INTESTINAL 
HAEMORRHAGE;  8.  HAEMORRHOIDS;  9.  HEPATIC  PAIN;  10.  JAtlNDICE,  ITS  PATHO- 
LOGY.— V.    DERANGEMENTS    OF    THE     NERVOUS    SYSTEM.         1.    ACHING    PAINS    IN    LIMBS; 

2.  BURNING  patches:  3.  neuralgia;  4.  cramps;  5.  headache — megrim;  f>. 
vertigo;  7.  convulsions;  8.  mania  ;  9.  paralysis:  10.  noises  in  the  ears  ;  11. 
sleeplessness;  12.  depression  of  spirits;  13.  irritability;    14.  the   typhoid 

STATE. 

Mil.  President,  Fellows  of  the  College,  and  Gentlemen, — 
Til  my  first  lecture  I  endeavoured  to  show  that  the  secretion  of 
bile  was,  perhaps,  the  least  important  of  the  functions  of  the 
liver ;  but  that,  in  the  first  place,  this  organ  contributed  greatly 
to  the  processes  of  sanguification  and  nutrition  of  the  tissues; 
and,  secondly,  that  it  was  probably  the  chief  seat  of  the  dis- 
integration of  albuminous  matter ;  while  even  the  secretion  of 
bile,  although  in  part  excrementitious,  was  mainly  destined  to 
assist  the  assimilation  of  the  food.  If  these  views  were  correct, 
I  pointed  out  that  the  existing  classification  of  the  functional 
derangements  of  the  liver,  founded  on  the  quantity  or  the 
quality  of  the  bile  in  the  stools,  had  become  obsolete  ;  and  I 
proposed  to  substitute  another,  founded  on  the  more  important 
functions  of  the  liver  and  on  the  derangements  which  the 
liver  excites  in  other  organs  of  the  body.  I  then  described 
some  of  the  derangements  of  nutrition  and  elimhiation  traceable 
to  the  liver,  and  I  now  proceed  to  consider  the  more  important 
disorders  coming  under  the  head  of  Abnormal  Disintegration. 

III.  Abnormal  Disintegration. 

Modern  investigations,  pathological  as  well  as  physiological, 
go  far  to  prove  that  one  of  the  chief  functional  derangements  of 


ABNORMAL    DISINTEGEATION. 


563 


the  liver,  if  it  be  not  the  foremost  of  all,  is  an  imperfect  dis- 
integration of  albuminous  matter,  or  its  non-conversion  into  a 
soluble  product  (urea),  which  can  be  readily  excreted  by  the 
kidneys.  A  strong  corroboration  of  the  correctness  of  this  view 
is  furnished  by  the  disease  known  as  acute  atrophy  of  the  liver, 
to  which  I  have  already  had  occasion  to  refer.     In  this  disease 


Fig.  35. — Laminated  cryKtalline      Fig.    36. — Needle-shaped  crystals   of   Tyrosin, 
masses  of  Leucin.  adhering  in  bundles  and  in  stellate  groups. 

there  is  a  rapid  destruction  of  the  secreting  tissue  of  the  liver, 
and  the  result  is  a  disappsarance  of  urea  from  the  urine, 
and  the  substitution  for  it  of  leucin  (C^H'^JSTO^)  and  tyrosin 
(C^H"]SrO^),  products   of  the  disintegration  of  albumen  more 


Fig.  37. — Globular  masses  composed  of  acicular  crystals  of  Tyrosin, 

complex  and  less  oxydised  than  lithic  acid  (C-^H'*N'*0^)  and 
urea  (CH^N^O),  which  are  also  found  in  abundance  in  the 
wasted  tissue  of  the  liver  (figs.  35,  36,  and  37).  The  substitu- 
tion of  leucin  and  tyrosin  for  a  portion  of  the  urea  of  the  urine 
takes  place  in  other  diseases  of  the  liver,  in  which  the  destruc- 
tion of  the  hepatic  tissue  is  less  rapid  and  less  extensive  than  in 

o  o  2 


564  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.        lect.  xv. 

acute  atrophy,  as,  for  example,  in  certain  cases  of  cirrhosis  and 
of  obstruction  of  the  common  bile-duct.     I  have  known  it  also 
to  occur  in  certain  febrile  diseases,  such  as  typhus  and  enteric 
fever,  in  which  the  hepatic  tissue  appears,  in  consequence  of 
the    increased  work  thrown   upon  it,  to  undergo  partial  dis- 
integration.'    But  these  important  changes  in  the  urine,  so  far 
as  we  know,  only  occur  in  cases  where  there  is  structural  change 
of  the  liver.     The  urine,  however,  is  liable  to   other  changes 
indicating  imperfect  disintegration  or  ox3^dation  of  albuminous 
matter,  which  are  much  more  common,  and  which  are  also  the 
result  of  functional  derangement  of  the  liver,  but  which  are  not 
necessarily  associated  with   structural   disease  of  that  organ. 
The  most  common  of  these  changes  in  the  urine  are  deposits  on 
cooling  of  lithic  acid,  lithates,  and  pigmentary  matters  ;  but 
there  are  probably  others,  less  frequent  and  as  yet  but  little 
studied,  such  as  the  presence  of  xanthin,  cj^stin,  kreatinin,  etc. 
I  need  not  remind  an  audience  such  as  that  which  I  have  the 
honour  to  address,  that  deposits  in  the  urine  of  lithic  acid  or 
lithates  are  not  due  to  any  morbid  condition  of  the  kidneys. 
What  I  wish  to  insist  upon  is,  that  the  frequent  occurrence  of 
these  deposits  in  the  urine  ought  always  to  be  regarded  as  a 
sign  of  functional  derangement  of  the  liver,  arising  from  causes, 
sometimes  temporary,  at  other  times  more  or  less  permanent. 
Excluding  those  cases  in  which  deposits  of  lithic  acid  or  lithates 
are  thrown  down  in  the  urine  not  until  twelve  or  twenty  hours 
after   its  emission,  as  the    result  of   spontaneous    changes,  to 
which  Scherer  has  given  the  name  of  acid  urinary  fermenta- 
tion,^  and  those  which  are  due  to  a  marked  deficiency  of  urinary 
water,  deposits  of  lithic  acid,  lithates,  and  abnormal  pigments, 
which  appear  in  the  urine  as  soon  as  it  cools,  are  chiefly  met 
with  under  the  following  conditions  : — 

1.  In  febrile  diseases,  in  which  we  know  that  the  liv(H' 
becomes  enlarged  and  congested,  and  its  gland-cells  loaih'd 
Avith  minute  granules,  and  in  wliich  there  always  is  an  in- 
creased disintegration  of  albuminous  matter.  Everyone.  I'^r 
example,  is  familiar  with  the  copious  deposits  of  lithates  wliidi 
are  so  common  during  an  attack  of  ordinary  febrile  catarrh. 

'  See  IMnroliison  on  The  CDiitiimofl  Fevers  of  fii'cal  IJritain,  2nil  edit.  1873.  ]'ii. 
lo7.  210,  2')5,  .')33.  629. 

^  Ann.  d.  Chemie  und  Pliarm.,  Bd.  42,  p.  171.  T>r.  Bence  Jones's  experinienls 
throw  doiilils  upon  the  oeeiirrenee  of  tlie  iicid  fHrnienlalion  iu  the  urine  descriljcd  l.y 
Scherer,  Lect.  on  J'atli.  and  Tiicrap.  1807,  ]'■  -'Hi. 


LKCT.  XV.  ABNORMAL    DISINTEGRATION.  565 

2.  In  many  structural  diseases  of  the  liver,  and  particularly 
in  those  which  are  characterised  by  an  increased  amount  of 
blood  in  the  organ,  such  as  inflammation,  cirrhosis,  cancer,  and 
simple  hyperseraia,  whether  mechanical  or  active. 

0.  In  functional  derangements  of  the  liver,  either  temporary 
or  persistent. 

To  this  third  cause  of  an  excess  of  lithic  acid  in  the  urine  I 
wish  now  to  restrict  my  remarks.  What  I  desire  to  maintain 
is,  that  lithuria,  like  glycosuria,  is  very  often  due  to  a  func- 
tional disease  of  the  liver,  although  even  glycosuria  is  still 
ranged  in  some  text-books  with  albuminuria  and  diseases  of  the 
kidneys.  In  other  words,  abnormal  disintegration  of  albu- 
minous matter  in  the  liver  may  lead  to  a  morbid  condition  of 
the  blood  and  of  the  entire  system,  which  often  manifests  itself 
in  lithuria.  This  morbid  state  of  the  blood  I  propose  to 
designate  Lithsemia.^ 

1.  Lithcemia. — When  oxydation  is  imperfectly  performed  in 
the  liver  there  is  a  production  of  insoluble  lithic  acid  and 
lithates,  instead  of  urea  which  is  the  soluble  product  resulting 
from  the  last  stage  of  oxydation  of  nitrogenous  matter. 
Persons  who  habitually  enjoy  the  best  of  health  are  liable  to 
deposits  of  lithates  in  the  urine  after  a  surfeit  of  food,  or  even 
after  partaking  moderately  of  one  of  the  fashionable  dinners 
of  the  age.  When  more  food  is  taken  into  the  blood  than  is 
necessary  for  the  nutrition  of  the  tissues,  the  excess  is  thrown 
off'  by  the  kidneys,  lungs,  and  skin  in  the  form  of  urea,  carbonic 
asid  and  water,  or  in  the  imperfectly  oxydised  forms  of  lithic 
acid  and  oxalic  acid.  Under  these  circumstances,  an  excess  of 
work  is  thrown  upon  the  liver  and  the  other  glandular  organs, 
and  one  result  is  that  a  quantity  of  albumen,  instead  of  being 
converted  into  urea,  is  discharged  by  the  kidneys  in  the  less 
oxydised  form  of  lithic  acid  or  its  salts.  But  what  in  most 
persons  is  an  occasional  result  of  an  extraordinary  cause  is  in 
some  almost  a  daily  occurrence,  either  from  the  food  being 
always  excessive  in  amount  or  unduly  stimulating,  or  from 
some  innate  defect  of  power,  often  hereditary,  in  the  liver,  in 
virtue  of  which  its  healthy  functions  are  liable  to  be  deranged 
by  the  most  ordinary  articles  of  diet.     Most  persons  appear  to 

'  It  has  been  pointed  out  to  me  that  Dr.  Austin  Flint  has  proposed  the  term 
'  uricsemia'  to  designate  the  excess  of  uric  acid  in  gout  and  in  cases  of  lead-poisoning 
(Principles  and  Practice  of  Medicine,  3rd  edit.  Philadelphia,  1868,  p.  86).  The  term 
which  I  have  employed  appears  to  me  to  be  preferable. 


5d6  FUNCTIONAL    DERANGEMENTS    OP    THE    LIVER.        iect.  xv. 

have  more  liver,  jast  as  they  have  more  hmg,  than  is  absolutely 
necessary  for  the  due  performance  of  its  functions.  But  in 
others,  not  unfrequently  the  offspring  of  gouty  parents,  the 
organ  in  its  natural  condition  seems  only  just  capable  of  per- 
forming its  healthy  functions  under  the  most  favourable  cir- 
cumstances, and  functional  derangement  is  at  once  induced  by 
articles  of  diet  which  most  persons  digest  with  facility.  This 
functional  derangement  may  manifest  itself  by  various  sym- 
ptoms of  'indigestion,'  by  disturbances  of  circulation  and  of 
other  physiological  systems,  but  especially  by  deposits  of  lithic 
acid,  lithates,  and  pigments  in  the  ui^ine.  These  deposits,  it  is 
true,  are  often  absent,  and  yet  the  urine  may  contain  a  great 
excess  of  lithic  acid.  Indeed,  as  Dr.  Bence  Jones '  has  shown, 
clear  urine  sometimes  contains  more  lithic  acid  than  that  which 
thickens  on  cooling.  But  the  frequent  deposit  of  lithates  shows 
that  oxydation  is  less  perfect  than  it  ought  to  be.  Very  often, 
however,  these  urinary  deposits  exist  for  years,  without  the 
patient  experiencing  any  general  or  local  discomfort.  But 
sooner  or  later,  often  about  middle  life,  lithic  acid  and  lithates 
are  formed  in  such  excess  that  they  cannot  be  eliminated  by  the 
ordinary  channels,  and  they  accumulate  and  create  disturbance 
in  different  parts  of  the  organism,  and  then  the  urinary  deposits 
begin  to  attract  more  attention  than  they  had  previously  done, 
from  their  beizig  accompanied  by  symptoms  of  indigestion,  or 
from  the  evidence  of  some  serious  local  mischief,  the  onset  of 
which  had  been  insidious.  These  symptoms  are  all  the  more 
likely  to  occur  if  the  patient  be  what  is  commonly  known  as  '  a 
generous  liver,'  if  he  take  little  exercise  in  the  open  air,  or  if  he 
liave  much  mental  work.  Of  the  symptoms  referred  to,  the 
most  common  are  the  following :  - 

a.  A  feeling  of  weight  and  fulness  at  the  epij^astrium  and 
in  the  region  of  the  liver. 

h.  Flatulent  distension  of  the  stomach  and  bowels. 

c.  Heartburn  and  acid  eructations. 

d.  A  feeling  of  oppression  and  often  of  weariness  and  aching 
pains  in  the  limbs,  or  of  insurmountable  sleepiness  after  meals. 

e.  A  furred  tongue,  which  is  often  large  and  indented  at  the 
edges,  and  a  clammy,  bitter,  or  metallic  taste  in  the  mouth, 
especially  in  the  morning. 

/.  Appetite  often  good  ;  at  other  times  anorexia  and  nausea. 

•  I'liilosopliicul  Transactions,  18-19,  part  ii.  p.  249. 


LECT.  XV.  ABNORMAL    DISINTEGRATION.  567 

g.  An  excessive  secretion  of  viscid  mucus  in  the  fauces  and 
at  the  back  of  the  nose. 

h.  Constipation,  the  motions  being  scybalous,  sometimes  too 
dark,  at  others  too  light,  or  even  clay-coloured.  Occasionally 
attacks  of  diarrhoea  alternating  with  constipation,  especially  if 
the  patient  be  intemperate  in  the  use  of  alcohol. 

i.  In  some  patients,  attacks  of  palpitation  of  the  heart,  or 
irregularity  or  intermission  of  the  pulse. 

A'.  In  many  patients,  occasional  attacks  of  frontal  head- 
ache. 

I.  In  many  patients,  restlessness  at  night  and  bad  dreams. 

m.  In  some  patients,  attacks  of  vertigo  or  dimness  of  sight, 
often  induced  by  particular  articles  of  diet. 

All  these  symptoms  are  liable  to  occasional  aggravation 
from  errors  in  diet.  Gradually  the  patient  is  taught  by  ex- 
perience to  become  more  careful  as  to  what  he  eats  or  drinks. 
One  thing  after  another  he  is  compelled  to  give  up.  First,  he 
renounces  malt  liquors ;  then  he  discovers  that  Port  wine, 
Madeira,  Champagne,  and  Burgundy  disagree,  and  he  betakes 
himself  for  a  time  to  dry  Sherry :  but  at  length  this  does  not 
suit,  and  after  aii  interval,  during  which  a  trial  is  made  of 
Claret  or  Hock,  the  patient,  probably  under  medical  advice, 
finds  temporary  relief  from  the  substitution  for  wines  of  brandy 
or  whisky  largely  diluted  with  water.  At  last,  unless  he  be 
misled  by  the  fashionable,  but  to  my  mind  erroneous,  doctrine 
of  the  present  day,  that  alcohol  in  one  form  or  another  is 
necessary  for  digestion  or  to  enable  a  man  to  get  through  his 
mental  or  bodily  work,  he  finds  that  he  enjoys  best  health  when 
he  abstains  altogether  from  wine  and  spirits  and  drinks  plain 
water.  The  patient  goes  through  a  like  experience  with  regard 
to  solid  food  ;  one  dish  after  another,  very  often  what  he  likes 
best,  has  to  be  given  up,  until  at  length,  if  he  be  well  advised 
and  have  the  sense  to  follow  the  advice,  he  restricts  himself  to 
the  plainest  food  in  moderate  quantity.  As  a  rule,  those 
articles  of  diet  are  most  apt  to  disagree  which  contain  much 
saccharine  or  oleaginous  matter,  and  not,  as  might  perhaps 
have  been  expected,  nitrogenous  food,  plainly  cooked.  In  most 
of  these  cases  the  digestion  appears  to  be  strongest  in  the 
morning,  and  the  patient  suffers  from  late  dinners  or  suppers. 

The  picture  which  I  have  thus  imperfectly  drawn  represents 
a  morbid  condition  extremely  common  in  this  country,  which 
is  associated  with  a  constant  tendency  to  the  deposit  of  litbic 


568  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.         lect.  xv. 

aeicl  OT  litliates  in  the  urine,  and  wkieli,  for  the  reasons  already 
g-iven,  I  believe  to  originate  in  functional  derangement  of  the 
liver. 

2.  Croid.  But,  secondly,  you  cannot  fail  to  recognise  that 
this  picture  represents  a  train  of  symptoms  very  common  in 
gouty  people,  and  to  which  the  terms  '  gouty  dyspepsia,'  '  latent 
gout,'  '  suppressed,'  '  anomalous,'  or  '  irregular  gout '  have  been 
applied ;  although  what  I  desire  to  m-aintain  is,  that  they  are 
also  very  common  in  persons,  who  neither  inherit  articular  gout 
nor  ever  have  it  themselves.  Gout  itself,  however,  is  merely 
one  of  the  results  of  lithsemia.  Thanks  to  the  researches  of  our 
colleague  Dr.  Garrod,  we  now  know  that  gouty  inflammation 
of  a  joint  is  due  to  various  exciting  causes,  which  it  is  needless 
here  to  enumerate,  determining  a  local  deposit  of  lithate  of 
sod-a,  which  has  previously  existed  in  abnormal  quantity  in  the 
blood,  as  well  as  in  the  fluid  that  exudes  from  it  into  all  the 
textures  of  the  body.  The  accumulation  of  this  substance  in 
the  blood  will,  no  doubt,  be  favoured  by  non-elimination  con- 
sequent upon  disease  of  the  kidneys ;  but  in  most  cases  of  gout 
the  kidneys  are  in  the  first  instance  healthy,  and  the  presence 
in  the  blood  or  tissues  of  lithic  acid  or  its  salts  is  the  resiilt 
of  imperfect  digestion,  or  more  strictly  of  functional  derange- 
ment of  the  liver.  Articular  gout  is,  so  to  speak,  a  local 
accident,  which,  though  sometimes  determined  by  an  injury, 
yet  may  occur  at  any  time  in  x)ersons  in  whom  the  noi-mal 
process  by  which  albuminous  matter  becomes  disintegrated  in 
the  liver  into  urea  is  persistently  deranged.  In  other  words, 
gout,  like  diabetes,  is  the  result  of  a  functional  derangement 
of  the  liver;  and  just  as  we  found  that  in  many  persons  in 
whom  there  is  no  evidence  of  articular  gout,  an  innate  defective 
power  of  the  liver,  in  virtue  of  Avhich  its  functions  are  deranged 
with  unusual  facility,  is  often  transmitted  by  parents  to  their 
offspring,  so  gout,  which  is  one  of  the  consequences  of  that 
condition,  comes  to  be  an  hereditary  disease.  1  hold,  therefore, 
that  what  is  called  a  '  gouty  diathesis '  always  indicates,  and  is 
the  result  of,  hepatic  derangement,  and  that  many  symptoms 
commonly  referred  to  gout  would  be  more  correctly  ascribed  to 
disorder  of  the  liver. 

3.  Urinary  Calculi  are  another  consequence  of  lithamia, 
and  therefore  of  functional  derangement  of  the  liver.  Of  the 
concretions  which  form  in  the  urinary  passages  the  great 
majority  consist,  in  the  first  instance  at  all  events,  of  lithic 


LECT.  XT.  ABNORMAL    DISINTEGEATION.  5^9 

acid  or  its  salts.  According-  to  Dr.  William  Eoberts,  litliic  acid 
constitutes  five-sixths  of  all  renal  concretions  and  of  vesical 
calculi  which  have  only  recently  descended  from  the  kidney.' 
The  circumstances  favourable  to  the  precipitation  of  lithic  acid 
are  catarrhal  and  other  morbid  states  of  the  urinary  passages 
and  an  acid  condition  of  the  urine,  but  mainly  an  excessive 
elimination  by  the  kidneys  of  free  lithic  acid,  which  had  pre- 
viously existed  (either  free  or  combined)  in  excess  in  the  blood, 
and  which  we  have  seen  to  be  formed,  mainly  at  all  events,  in 
the  liver.  There  are  also  good  reasons  for  believing  that  renal 
calculi  composed  of  otlier  substances  than  lithic  acid  have 
a  hepatic  origin.  Cystin  (C^H^JN'SO^),  for  example,  which 
represents  a  different  process  of  oxydation  from  that  which 
produces  lithic  acid,  closely  resembles  taurin,  and,  like  it, 
contains  a  large  proportion  of  sulphur ;  '^  and,  moreover,  it  has 
been,  found  by  Scherer  in  the  livers  of  patients  suffering  from 
enteric  fever.^  It  would  seem,  therefore,  that  those  rare  renal 
calculi  which  are  composed  of  cystin  are  due  in  the  first  instance 
to  some  fmictional  derangement  of  the  liver.  Xanthin  (C^H* 
N'^O'^),  again,  of  which  a  few  renal  calculi,  cliiefl}^  in  young 
people,  are  composed,  also  appears  to  arise  from  imperfect 
oxydation  of  the  products  of  albuminous  matter.  It  differs 
from  lithic  acid  only  in  containing  one  atom  less  of  oxygen  ;  so 
that  it  also  is  probably  formed  in  the  liver,  in  which  organ  it 
has  been  found  by  Scherer,  as  well  as  in  the  blood,  spleen,  and 
muscles.*  Even  oxalate  of  lime,  which  Dr.  Bence  Jones  found, 
either  alone  or  combined  with  other  substances,  in  163  out  of 
450  urinary  calculi,'''  may  in  some  way  be  connected  with 
functional  derangement  of  the  liver,  although  the  evidence  on 
this  point  is  less  clear  than  in  the  case  of  otlier  urinary  con- 
cretions. I  do  not  forget  that  it  was  maintained  by  so  eminent 
an  authority  as  our  colleague  Dr.  Owen  Eees,  in  the  Croonian 
Lectures  delivered  before  this  College  in  1856,  that  oxalic  acid 
is  never  excreted  from  the  blood,  but  is  always  formed  in  the 
urine  after  its  secretion  by  decomposition  of  lithic  acid ;  and 
that  this  opinion  has  more  recently  been  advocated  by  another 
eminent  Fellow  of  this  College,  Dr.  Bashani.*'     Facts,  however, 

'   Urinary  and  Eenal  Diseases,  2nd  edit.  1872,  p.  270. 

-  Eoberts,  op.  eit.  2nd  edit.  1872,  p.  84. 

3  Archiv.  f.  Path.  Anat.  Ed.  x.  p.  228. 

••  Roberts,  op.  eit.  p.  88. 

^  Lectures  on  Pathology  and  Therapeutics,  1867,  p.  09. 

«  Renal  Diseases,  1870,  p.  187. 


5/0  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.        lkct.  xv. 

are  now  known  wliicli  point  strongly  to  an  opposite  conclusion. 
For  example,  oxalic  acid  and  its  compounds,  when  introduced 
into  the  stomach,  will  appear  as  oxalate  of  lime  in  the  urine  ; 
while  in  one  case,  at  least,  oxalic  acid  has  been  found  in  the 
blood  by  Dr.  Garrod.^  It  has  also  been  found  in  saliva,  in 
perspiration,  and  in  mucus.  The  researches  also  of  Beneke  - 
make  it  probable  that  the  chief,  if  not  sole,  source  of  oxalic 
acid  is  impeded  metamoi'phosis  of  the  nitrogenous  constituents 
of  the  blood  and  food;  while,  from  its  composition  (C^H-0^), 
it  appears  to  be  one  of  the  penultimate  stages  in  the  oxydation 
.of  the  more  comjslex  organic  substances  into  carbonic  acid  and 
water.  What  part  of  the  system  is  in  these  cases  mainly  at 
fault  is  not  very  clear,  although  we  are  quite  certain  that  the 
liver  contributes  greatly  to  the  disintegration  of  albuminous 
matter ;  and  it  seems  not  improbable  that,  when  an  excess  of 
lithic  acid  is  formed  in  the  liver,  a  portion  of  it  may  be  sub- 
sequently converted  into  oxalic  acid.  Wohler  has  succeeded 
in  obtaining  oxalic  acid  from  lithic  acid  out  of  the  body  ;  while 
Scbunck  -*  and  other  chemists  distinctly  state  that,  within  the 
body,  oxalic  acid  is  formed  by  the  oxydation  of  lithic  acid. 
When  lithic  acid  is  imperfectly  oxydised  it  is  believed  to  break 
up  into  oxalic  acid  and  urea.  It  may  be  added,  that  oxalate 
of  lime  usually  coexists  or  alternates  with  lithic  acid  or  its  salts 
both  in  the  urine  and  in  urinary  calculi,  and  that  the  condition 
of  oxaluria,  as  was  long  ago  pointed  out  by  Dr.  Prout,'*  is  often 
associated  with  sj'mjDtoms  similar  to  those  which  are  common 
in  lithsemia,  such  as  irregularity  of  the  heart's  action,  inter- 
mission of  the  pulse,  palpitation,  flatulence,  and  hypochon- 
driasis. But  whether  the  liver  be  concerned  in  the  production 
of  oxaluria  or  not,  there  can  be  no  doubt  that  it  is  the  organ 
fundamentally  at  fault  in  the  great  majorit}'  of  cases  of  urinary 
calculi ;  and  that  it  is  to  it,  and  not  to  the  kidneys,  that  we 
must  mainly  look  for  their  prevention  and  treatment.  This 
pathological  inference  is  confirmed  by  clinical  experience.  One 
of  the  greatest  modern  authorities  on  urinary  calculi  states,  as 
the  result  of  his  observation,  that  patients  with  calculous 
disease  are  only  temporarily  benefited  by  the  alkaline  waters  of 
Vichy  and  Vals,  which  dihite  the  urine  and  render  it  alkaline, 

'  ]\Iidico-Chirurgie;il  Transac-tions,  1848. 

-  Ziir  Ent-\vickliiiigsgescliichte  d.  Oxaluria,  T".  W.  IkiiekL',  18o2. 

^  Proceeilings  of  tlu^  Royal  Society,  \o  90. 

*  Stomach  and  Eenal  Diseases,  p.  62. 


j.ECT.  XV.  ABNORMAL    DISINTEGEATION.  5/1 

but  do  not  cure  the  disease  ;  whereas  more  permanent  results  are 
obtained  by  the  use  of  the  waters  of  Friedrichshall,  Carlsbad, 
and  Plillna,  which  produce  activity  in  all  the  digestive  organs, 
and  eliminate  by  other  channels  the  waste  matters  previously 
thrown  out  as  lithic  acid  by  the  kidneys,  but  which  mainly  act 
by  relieving  the  overloaded  liver  and  restoring  its  normal 
functions. 

4.  Biliary  Calculi,  which  consist  for  the  most  part  of  choles- 
terin  and  bile-pigment,  are  another  result  of  functional  de- 
rangement of  the  liver.  They  are  chiefly  met  with  in  persons 
of  middle  or  advanced  life  who  have  led  sedentary  lives,  and 
they  are  particularly  common  in  those  who  have  lived  too  well 
and  eaten  much  saccharine  food,  and  who  are  the  subjects  of 
lithsemia.  It  may  be  difficult  to  explain  how  the  functional 
derangement  of  the  liver  which  results  in  lithseraia  should  also 
lead  to  the  formation  of  concretions  composed  of  cholesterin 
and  bile-pigment  in  the  biliary  passages ;  but  the  frequent 
concurrence  of  the  lithic  acid  dyscrasia  with  gall-stones  is  a 
clinical  fact  which  I  have  had  many  opportunities  of  verifying. 
This  observation  accounts  for  the  frequent  occurrence  of  biliary 
calculi  in  gouty  people,  and  it  also  explains  the  frequent  coin- 
cidence in  the  same  individual  of  gall-stones  and  urinary 
calculi.  I  cannot  agree  with  Frerichs  in  regarding  this  coinci- 
dence as  purely  accidental.^  Many  years  ago  Baglivi  and 
Morgagni  insisted  on  the  frequent  coexistence  of  urinary  and 
bihary  calculi.  The  late  Dr.  Prout  also  remarked  that  the 
formation  of  gall-stones  of  cholesterin  was  frequently  associated 
with  a  tendency  to  lithic  acid  deposits  in  the  urine ;  and  Dr. 
George  Budd,  in  his  classical  work  on  Diseases  of  the  Liver, 
states  that,  '  the  habit  of  drinking  porter,  which  frequently 
leads  to  lithic  acid  deposits  and  to  the  most  inveterate  forms  of 
gout  in  persons  who  inherit  no  disposition  to  them,  may  also 
li-equently  lead  to  the  formation  of  gall-stones.'  ^  Lastly,  the 
intimate  relation  between  urinary  calculi,  biliary  calculi,  and 
gout  was  in  accordance  with  the  great  clinical  experience  of 
the  late  Professor  Trousseau,^  and  of  late  years  has  been  strongly 
insisted  on  by  his  countryman,  Dr.  Senac  of  Yichy.''  In  con- 
nection with  these  remarks  it  may  be  worth  adding  that,  in  a 

'    Klinik  der  Leberkrank.,  Sydenham  Society's  translation,  vol.  ii.  p.  oil. 

2  3rd  edit.  p.  369. 

^  Clinical  Lectnre.s,  Sydenham  Society's  Ovlit.  vol.  iv.  p.  LSI. 

*  Coliques  lltpatiques,  Par'.s,  1870,  p.  84. 


^z- 


FUNCTIONAL    DERANGEMENTS    OF    THE    LIVEE.         lect.  xv. 


few  instances,  litliic  acid  lias  been  found  in  biliary  concretions.^ 
(See  also  Lecture  XIII.,  p.  514.) 

5.  Degeneration  of  the  Kidneys. — From  wliat  has  been 
already  stated  it  is  clear  that  the  kidneys  and  the  liver  are 
intimately  connected  in  their  functions,  the  main  object  of  the 
kidneys  being  to  eliminate  certain  products  which  are  in  great 
part  secreted  in  the  liver.  Derangements  of  one  organ  are, 
therefore,  very  likely  to  lead  to  disorder  of  the  other.  In  the 
first  place  my  experience  has  led  me  to  regard  lithsemia  as  one 
of  the  chief  causes  of '  acute  Bright's  disease '  or  acute  nephritis. 
Most  cases  of  this  disorder  are  traceable  either  to  scarlatina  or 
to  a  chill.  In  patients  under  twenty  years  of  age  few  cases 
cannot  be  traced  to  scarlatina.  In  adults,  when  the  attack 
follows  a  chill,  and  there  has  been  no  antecedent  attack  of 
scarlatina,  it  will  almost  invariably  be  found  that  the  patients 
have  previously  suffered  from  derangements  of  the  liver  with 
lithsemia,  while  many  have  led  intemperate  lives.  Again,  we 
find  that  functional  derangement  of  the  liver  resulting  in 
lithsemia,  with  dyspeptic  symptoms  such  as  those  which  I  have 
described,  is  a  common  cause  of  the  contracted,  granular,  or 
gouty  kidney.  Our  colleague  Dr.  George  Johnson,  one  of  the 
greatest  living  authorities  on  diseases  of  the  kidneys,  thus  writes 
respecting  the  causes  of  this  form  of  Bright's  disease  : — '  It  is 
often  associated  with  the  gouty  diathesis,  as  one  of  its  syno- 
nyms indicates  ;  and  it  is  of  common  occurrence  in  persons  who 
eat  and  drink  to  excess,  or  who,  not  being  intemperate  in  food 
or  drink,  suffer  from  certain  forms  of  dyspepsia,  without  the 
complication  of  gouty  paroxysms.'  And  further  on,  in  the 
lecture  from  which  I  have  just  quoted,  he  observes  : — '  Dysj^ep- 
sia  is  frequently  associated  with  this  form  of  disease,  sometimes 
as  a  cause,  sometimes  as  a  consequence.  You  may  often  learn 
that  a  patient  of  strictly  temperate  habits  has  for  months  or 
years  suffered  from  pain  or  uneasiness  after  food,  flatulent 
distension  of  the  stomach  and  bowels,  habitual  looseness  or 
irregularity  of  the  bowels,  constipation  and  diarrhcea  alter- 
nately. With  this,  there  is  often  turbidity  of  the  urine,  which 
is  high-coloured,  excessively  acid,  and  deposits  urates  abun- 
dantly. After  a  time,  the  urine,  which  had  been  scanty,  be- 
comes more  copious,  of  pale  colour,  of  low  specific  gravity,  and 
is  found  to  contain  albumen  and  granular  casts.    In  such  a  case 

'  rrcrichs,  op.  cit.  vol.  ii.  p.  197. 


LECT.  XV.  ABNORMAL    DISINTEGRATION.  573 

probably  renal  deoeneration  is  a  consequence  of  the  long-continued 
elimination  of  products  of  faulty  dirjestion  through  the  kidneys.  I 
have  seen  this  sequence  of  events  so  frequently,  that  I  have  no 
doubt  as  to  their  causative  relationship.  Dyspeptic  symptoms, 
such  as  I  have  described,  and  consequent  I'enal  degeneration. 
are  in  some  cases  excited  or  greatly  aggravated  by  habitual 
excess  of  alcohol.'  ^  Numerous  cases  which  have  come  under 
my  own  observation,  and  which  I  have  carefully  watched,  have 
satisfied  me  as  to  the  strict  accuracy  of  Dr.  Johnson's  descrip- 
tion ;  but  the  dyspepsia  which  so  commonly  precedes  the  first 
symptoms  of  contracted  kidney  is  that  which  I  have  already 
described  as  accompanying  persistent  lithsemia,  and  as  con- 
sisting in  derangement,  not  so  much  of  the  gastro-intestinal 
digestion,  as  of  the  disintegrative  processes  which  go  on  in  the 
liver. 

Chronic  degeneration  of  the  kidneys  with  albuminuria  is 
sometimes  also  a  sequel  of  diabetes,  the  kidneys  becoming- 
diseased  from  the  constant  irritation  of  the  saccharine  urine. 
This  is  another  way  in  which  functional  derangement  of  the 
liver  may  lead  to  structural  disease  of  the  kidneys. 

There  are  also  reasons  for  believing  that  albuminuria 
may  be  induced  b}^  hepatic  derangement  independently  of 
structural  disease  of  the  kidneys.  It  is  now  generally  acknow- 
ledged that  albuminuria,  even  when  copious,  and  in  the  absence 
of  any  acute  febrile  disorder,  does  not  necessarily  indicate 
renal  disease.  Very  often  in  these  cases  the  albuminuria  is 
intermittent  or  remittent,  and  the  albumen  has  jDeculiar 
chemical  characters,  the  previous  addition,  for  example,  of  a 
few  drops  of  mineral  acid  preventing  to  an  unusual  extent 
the  subsequent  coagulability  by  heat.^  Errors  in  diet  are  one 
of  the  most  common  causes.  In  some  persons,  jDeculiarly 
constituted,  temporary  albuminuria  is  a  constant  result  of 
certain  articles  of  food,  such  as  uncooked  eggs.  In  several 
instances  I  have  known  the  urine  passed  at  night  to  contain 
albumen,  often  associated  with  lithates  and  a  high  specific 
gravity,  whereas  the  morning  urine  was  clear,  of  low  sjDecific 
gravity,  and  contained  no  albumen.  Again,  in  certain  cases 
of  exophthalmic  goitre  the  urine  at  some  hours  of  the  day, 

>  British  Medical  Journal,  1873,  vol.  i.  pp.  Ifil,  191. 

^  See  Dr.  Basliam's  work  on  Dropsy,  1863,  also  his  work  on  Renal  Disease?,  1870, 
p.  216  ;  Dr.  Learoii,  Med.  Times  and  Ga-?.,  Oct.  26,  1867 ;  andP.  Lorain,  De  rAlbunii- 
uurie,  Paris,  1860,  p.  67. 


574  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.         i.ect.  xv. 

usually  after  food,  is  loaded  with  albumen,  whereas  at  others 
it  contains  none ;  and  this  state  of  matters  may  last  for  many 
months,  and  then  completely  disappear.^  Now  it  is  not  con- 
tended that  in  all  these  cases  the  liver  is  the  organ  primarily  at 
fault,  but  certainly  in  some  there  is  good  reason  for  believing- 
it  to  be  so,  the  albuminuria  being  unattended  by  any  other 
symptom  of  renal  disease,  varying  greatly  in  quantity  and 
sometimes  absent,  and  the  urine  being  of  normal  quantity,  of 
high  specific  gravity,  and  habitually  loaded  with  lithates,  lithic 
acid,  oxalates,  and  pigments,^  and  there  being  very  often 
cutaneous  eruptions,  dyspepsia,  and  other  evidence  of  hepatic 
derangement.  I  have  met  with  several  instances  of  this  sort 
where  the  patient  was  subject  to  severe  attacks  of  what  at  first 
seemed  to  be  hepatic  colic,  but  where  there  was  no  jaundice 
and  the  paroxysm  was  followed  by  a  temporary  yet  extra- 
ordinary increase  of  lithates  and  albumen  in  the  urine,  Lastl}^, 
so  often  have  I  observed  albuminuria  associated  with  hepatic 
disorder,  which  has  disappeared  completely  and  permanently 
when  this  has  been  set  to  rights,  that  I  have  little  doubt  that 
we  have  in  the  liver  a  cause  of  albuminuria  to  which  attention 
has  not  hitherto  been  sufficiently  directed.^  The  pathology  of 
the  albuminuria  in  these  cases  may  be  similar  to  that  of  certain 
cases  of  diabetes  already  referred  to,  the  liver  having  too  much 
work  to  do,  and  permitting  some  albumen  to  pass  through  in  a 
form  which  cannot  be  assimilated ;  or  possibly  there  may  be 
some  defect  in  the  destructive  functions  of  the  liver,  in  con- 
sequence of  which  the  albuminous  matter,  instead  of  being 
converted  into  urea,  does  not  even  reach  the  stage  of  lithic  acid. 
It  is  possible  that  in  many  of  the  cases  now  referred  to  the 
albuminuria  may  indicate  an  early  stage,  not  yet  described,  of 
the  contracted  or  gouty  kidney,  yet  it  is  certain  that  the 
symptom  may  persist  or  recur  during  many  years  without  any 

^  See  somo  interostinn:  c:iscs  of  this  sort  recorded  by  tlie  lato  Dr.  J.  "Warliurton 
TJcghie,  Edin.Med.  Journ.  April  1874.  In  a  letter  to  Dr.  IJegbie  respecting  one  of  the.so 
ca.ses,  Dr.  George  Johnson  observes:  'I  have  often  met  with  cases  in  ■which  the  urine 
has  been  olbuminons  on'y  after  food  and  exercise.'  In  these  cases  botiiDr.  Eegbio  and 
Dr.  Johnson  coinridcd  in  tliinking  that  the  albuminuria  was  allied  to  the  albuminuria 
of  indigestion,  and  did  not  indicate  structural  disease  of  tlie  kidneys. 

Dr.  .Tames  Finlayson  has  found  numerous  hyaline  tube-casts  in  non-albuminnus 
urine  which  was  loaded  with  urea  and  lithates.  Brit,  and  For.  Med.  Chir.  Kev.  January 

1870. 

'  Dr.  W.  Whitln  has  rccrnlly  called  attention  to  tlie  influence  of  the  liver  in  de- 
termining botli  aiiaMiMM  .iiid  alliiuiiinuria.  Dublin  Journ.  of  Med.  .Science,  February 
1876. 


r,ECT.  XV.  ABNORMAL    DISINTEGRATION.  575 

other  symptom  of  renal  disease,  and  with  but  little  impairment 
of  the  general  health.^ 

6.  Structural  Diseases  of  the  Liver. — It  is  highly  probable 
that  derangement  of  the  disintegrative  processes  going  on  in 
the  liver  may  lead  to  structural  changes  in  the  liver  as  well  as  in 
the  kidneys.  In  the  first  place,  fatty  degeneration  of  the  liver  is 
well  known  to  be  a  common  lesion  in  persons  who  are  large 
feeders  or  drink  much  alcohol  and  lead  indolent  lives,  and  in 
whose  urine  there  are  often  copious  deposits  of  lithates.^  Under 
these  circumstances,  the  change  in  the  liver  is  sometimes  as- 
sociated with  a  similar  change  in  the  structure  of  the  heart  or 
kidneys,  or  with  general  corpulence.  Again,  in  a  large  pro- 
portion of  the  cases  of  catarrhal  jaundice,  occurring  towards 
middle  or  in  advanced  life,  the  patients  have  either  previous]}- 
suffered  from  actual  gout,  or  they  have  been  the  subjects  of 
lithsemia,  with  some  of  the  symptoms  of  dyspepsia  already  de- 
scribed as  accompanying  it.  Thirdly,  although  cirrhosis  is  most 
commonly  the  result  of  the  direct  irritation  of  the  liver  by  alco- 
hol, there  are  certain  cases  in  which  it  cannot  be  traced  to  such  a 
source,  but  in  which  its  symptoms  have  been  preceded  for  years 
by  the  lithic  acid  dyscrasia  and  dyspepsia.  Cases  of  this  sort 
have  come  under  my  own  notice,  and  have  been  described  by 
Baglivi,  Stoll,  Scudamore,  and  Trousseau  as  a  '  chronic  gouty 
hepatitis.'  ^  Lastly,  if  we  carefully  investigate  the  antecedent 
medical  history  of  patients  suffering  from  primary  cancer  of  the 
liver,  we  often  find  that  for  many  years  they  have  been  '  bilious,' 
or  they  have  been  liable  to  dyspeptic  symptoms  attended  by 
copious  deposits  of  lithic  acid  or  lithates  in  the  urine,  cither 
habitually  or  from  the  slightest  error  in  diet.  That  protracted 
derangement  of  cell-function  should  ultimately  lead  to  abnor- 
mal cell-formation,  in  persons  predisposed  to  cancer,  does  not 
appear  to  be  an  unwarrantable  assumption. 

'  Dr.  Basham  has  communicated  to  mc  two  such  cases  which  have  been  under  hi.s- 
ohservalion,  one  for  sixteen,  and  the  other  for  ten  years.  In  the  latter  the  patientJ 
follows  the  active  duties  of  the  medical  profession,  and  since  he  CHme  under  Dr. 
Easham's  notice  has  married  and  become  the  father  of  four  remarkably  healthy 
children. 

^  Fatty  liver  is  also  very  common  in  a  very  different  condition  of  the  system,  viz. 
in  wasting  diseases,  such  as  phthisis  and  chronic  dysentery.  It  is  supposed  that  the 
blood  in  these  cases  becomes  charged  with  thp  oily  matter  which  is  rapidly  ab- 
sorbed from  the  patient's  tissues,  and  that  a  portion  of  this  becomes  arrested  in  the 
liver. 

*  0.  Fcuilamore,  Nature  and  Cure  of  Gout,  4th  edit.  1823,  p.  43  ;  Trousseau,  op. 
cit.  vol.  iv.  p.  381. 


576  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.        lect.  xt. 

7.  Degeneration  of  Tissue  throughout  the  Body. — -Witli  the 
approach  of  old  age  there  is  a  tendency  of  the  tissues  through- 
out the  body  to  undergo  degeneration  and  decay,  fatty,  and 
sometimes  calcareous  matter,  being  substituted  for  the  normal 
structures.  More  than  twenty  years  ago  it  was  pointed  out  b}^ 
Mr.  Barlow,'  that  the  '  climacteric  disease '  described  by  a 
former  President  of  this  College,  Sir  Henry  Halford,  and  the 
'  Decline  of  the  Vital  Powers  in  Old  Age '  described  by  Dr. 
Marshall  Hall,  were  in  great  measure  due  to  these  degenerations, 
and  the  fact  is  now  generally  acknowledged.  In  no  organs  are 
these  degenerations  more  marked,  or  the  cause  of  greater 
danger  to  life,  than  in  the  heart  and  in  the  coats  of  the  arteries, 
the  degenerations  of  which  lie  at  the  foundation  of  apoplexy, 
paralysis,  aortic  incompetence,  and  other  maladies  of  advanced 
life.  The  explanation  of  these  degenerations  of  tissue  is  to  be 
found  in  derangements  of  the  nutritive  and  disintegrative  pro- 
cesses in  which  the  liver  pla^^s  so  important  a  part ;  and  in 
many  instances,  I  do  not  say  in  all,  it  is  the  liver  which  appears 
to  be  primarily  at  fault.  The  nutrition  of  the  tissues  becomes 
impaired,  partly  perhaps  in  consequence  of  the  supply  of  faulty 
nutritive  material,  but  mainly  from  the  functional  activity  of 
the  liver  becoming  weakened  with  advancing  age,  as  the  result 
of  which  the  blood  and  juices  of  the  body  are  impregnated  with 
a  quantity  of  disintegrated  albuminous  matter,  not  sufficiently 
oxydised  to  be  eliminated  by  the  kidneys.  But  what  in  many 
persons  is  merely  a  form  of  senile  decay  may,  under  certain 
conditions,  occur  at  a  comparatively  early  period  of  life.  Many 
observations  have  satisfied  me  that  persons  who  habitually 
consume  a  large  quantity  of  rich  and  stimulating  food  or  of 
alcoholic  drinks,  who  take  little  exercise,  and  whose  urine  is 
constantly  loaded  with  an  excess  of  lithic  acid  and  lithates,  are 
particularly  prone  to  fatty  degeneration.  Andral  and  Lobstein 
long  ago  connected  atheroma  of  the  vessels  with  '  a  particular 
taint  of  the  fluids  closely  resembling  gout,'  ^  and  it  has  been  a 
common  observation  by  physicians  practising  at  spas  resorted  to 
by  gouty  patients,  and  borne  out  by  my  own  experience,  that 
atheroma  of  the  arteries  at  an  unusually  early  period  of  life, 
and  diseases  of  the  aortic  valves  which  are  not  congenital  and 

'  ricnrral  OliSfrvalions  on  I'iitty  Dogcnoration,  MciUcmI  Times  and  Gazette,  ^[;iy 
]'>,  IK.Vi. 

-  ('.  Vj.  IIaR<^p,  Diseases  of  tlio  Organs  of  Cir^'ulation  ami  Ecsj'iii'ation,  Sydi'nliani 
Society's  Translation,  1816,  p.  82. 


LBCT.  XV.  ABNORMAL    DISINTEGEATION.  577 

are  independent  of  injury  or  rkeumatism,  are  met  with  far 
oftener  in  persons  who  are  the  subjects  of  the  lithic  acid 
dyscrasia,  or  who  have  had  gout,  than  in  those  who  have  no 
such  tendencies. 

8.  Local  Inflammations. — Lithsemia  predisposes  to  local  in- 
flammations. Persons  in  good  health,  not  apparently  so,  bat 
in  the  strictest  sense,  are  little  liable  to  local  inflammations. 
For  example,  when  a  given  number  of  persons  are  exposed  in 
common  to  an  exciting  cause  of  pneumonia,  comparatively  few 
are  attacked  with  that  disease ;  and,  when  the  previous  history 
of  those  attacked  is  investigated,  it  is  usually  found  that,  prior 
to  the  acute  attack,  they  have  been  in  an  abnormal  state  of 
health.  This  was  a  point  much  insisted  on  by  our  late  colleague 
Dr.  Todd.  In  one  of  his  remarkable  clinical  lectures,  he  writes 
as  follows  : — '  Simple  pneumonia  is  very  rare  in  another  sense 
also,  that  is,  in  its  freedom  from  complication  with,  or  depen- 
dence on,  some  peculiarity  of  constitution.  To  make  this 
clearer  to  you,  let  me  take  an  illustration.  If  two  men,  A  and 
B,  both  in  good  health,  be  exposed  to  some  noxious  influence — 
cold,  for  example — at  the  same  time,  and  for  the  same  period, 
A  will  get  a  severe  attack  of  pneumonia  and  B  will  not.  Now, 
at  first  sight,  one  "can  scarcely  conceive  why  the  pneumonia 
should  attack  the  one  and  not  the  other,  for  they  were  both 
apparently  equally  well  at  the  time  of  exposure  to  cold ;  but,  if 
we  carefully  examine  into  the  previous  history  of  these  indi- 
viduals, we  shall  find  that  A  is  of  a  gouty  or  strumous  constitu- 
tion, or  has  some  peculiarity  of  diathesis  which  B  does  not 
possess,  and  it  is  by  reason  of  this  that  A  is  seized  with  pneu- 
monia when  subjected  to  the  noxious  influence  which  produces 
no  such  injurious  effect  upon  B.'  ^  One  of  the  conditions  pre- 
disposing to  local  inflammations  is  gout,  but  the  dyscrasia 
which  I  have  designated  lithsemia,  and  of  which  gout  itself 
is  only  one  of  the  local  manifestations,  acts  in  the  same  way. 
Having  paid  considerable  attention  to  the  matter,  I  am  satisfied 
thab  persons  with  the  lithic  acid  dyscrasia  are  much  more  prone 
than  others  to  ordinary  febrile  colds,  as  well  as  to  more  severe 
local  inflammations.  They  may  appear  robust  and  healthy  up 
to  the  sudden  occurrence  of  the  inflammatoiy  attack,  but  they 
have  not  really  been  in  a  normal  sta+e  of  health.  I  have  also 
had  occasion  to  observe  that  in  certain  persons  who  habitually 
pass  an  excess  of  lithates  in  the  urine,  the  lithates  cease  to  be 
'  Clinical  Lectures  on  Acute  Diseases,  1860,  p.  367. 
P  P 


578  FUiyjCTIONAL    DERANGEMENTS    OF    THE    LIVER.        lect.  xv. 

eliminated  on  the  advent  of  a  local  inflammation  or  of  an 
ordinal'}^  febrile  catarrh,  to  be  again  discharged  in  abundance 
on  the  subsidence  of  the  pyrexia.  In  such  cases  the  retention 
of  lithates  in  the  system  has  probably  determined  the  local 
inflammation. 

9.  Constitutional  Diseases. — When  blood-poisons  are  taken 
into  the  system  from  without,  the  liver  is  one  of  the  organs 
which  first  and  mainly  suflPers  ;  but  I  trust  that  I  have  also 
made  it  clear  that  morbid  states  of  the  blood,  or  constitutional 
diseases,  such  as  gout  and  diabetes,  may  be  generated  in  the 
liver  from  derangeraents  of  the  processes  of  disintegration  and 
nutrition  which  normally  take  place  in  that  organ.  It  is  very 
probable,  indeed,  that  many  morbid  states  of  the  blood  and 
constitutional  diseases  have  their  origin  in  the  liver.  In  acute 
atrophy  of  the  liver,  the  liver  appears  to  be  in  some  instances, 
at  all  events,  the  starting-point  of  the  pathological  process, 
but  all  the  subsequent  phenomena  show  that  the  malady  is 
essentially  a  blood-disease.  In  certain  cases  of  erysipelas  and 
pyaemia,  I  have  long  taught  in  my  lectures  on  medicine  that 
the  mxderies  morhi  is  engendered  in  the  body ;  and  I  think  it 
might  be  shown  that,  as  in  acute  atrophy,  the  liver  is  the  organ 
at  first  mainly  at  fault. 

Again,  it  is  not  improbable  that  the  large  quantity  of  fibrin 
found  in  the  blood  in  acute  rheumatism  may  result  from  fibrin 
not  being  destroyed  in  the  liver  to  the  proper  extent.  In  acute 
rheumatism  there  is  often  a  history  of  antecedent  derangement 
of  the  liver,  which  seems  to  indicate  that  a  faulty  formation  of 
glycogen  or  its  too  free  or  rapid  conversion  into  lactic  acid,  may 
be  one  of  the  ways  in  which  this  substance  accumulates  in  the 
system.*  We  know,  also,  that  in  certain  states  of  the  body,  as 
after  surgical  operations,  childbirth,  and  acute  febrile  diseases, 
the  blood  is  very  prone  to  coagulate  in  the  large  vessels  ;  and 
that,  when  these  coagula  form  in  the  right  side  of  the  heart, 
sudden  death  may  result.  Our  colleague  Sir  Joseph  Fayrer  has 
shown  that  these  phenomena  are  much  more  common  in  India 
than  in  this  country  ;^  and,  since  the  commencement  of  these 
lectures,  he  has  written  to  me  to  suggest  that  tliis  may  be  due 
to  the  greater  tendency  to  hepatic  derangements  in  tropical 
countries. 

On  the  other  hand,  the  deficiency  of  red  blood-corpuscles  in 

'  Seo  Balthnzar  Foster,  Clin.  Lect.  1874,  p.  155. 

-  Clinical  and  Pathological  Observations  in  India,  1873. 


LECT.  XV.  ABNORMAL    DISINTEGRATION.  579 

anaemia,  clilorosis,  scrofula,  and  some  other  maladies  is  also 
probably  traceable,  in  the  first  instance,  to  functional  derange- 
ment of  the  liver.  There  can  be  no  doubt  that  patients  with 
protracted  functional  derangement  of  the  liv^er  are  often  very 
aiiEeraic.  They  present  a  pale,  pasty  appearance,  and  bear 
losses  of  blood  or  acute  diseases  badly.  Many  years  ago, 
Messrs.  Todd  and  Bowman  observed  that  persons  suffering  from 
functional  derangement  of  the  liver  are  often  pale,  as  if  from 
loss  of  blood,  although  no  such  loss  has  been  experienced ; 
their  nutrition  is  enfeebled  and  digestion  impaired,  and  there 
is  slight  yellowness  of  the  complexion,  as  in  cases  of  hepatic 
disease,  and  yet  after  death  no  lesion  is  discernible,  except 
perhaps  slight  enlargement  of  the  liver.'  In  these  cases,  iron 
may  disagree  "until  the  liver  has  been  restored  to  its  normal 
functions. 

Indeed,  it  seems  not  improbable  that  most  so-called  con- 
stitutional diseases  are  due  in  the  first  instance  to  some  defec- 
tive action  of  the  liver.  The  child  of  a  gouty  father  is  not  born 
with  the  materies  morbi  or  poison  of  gout  either  in  his  blood  or 
in  his  tissues ;  but  he  is  born  with  a  morbid  tendency  in  his 
liver  to  produce  that  poison.  The  same  may  perhaps  be  said  of 
cancer  and  of  tubercle.  Both  are  unquestionably,  like  gout, 
constitutional  and  hereditary  diseases ;  but  the  child  of  a 
cancerous  parent  is  not  born  with  the  materies  morbi  of  cancer 
in  his  blood  or  tissues,  but  only  with  a  tendency  to  a  certain 
form  of  abnormal  nutrition,  which  results  in  a  cancerous  growth. 
This  morbid  tendency,  resident  at  first,  no  doubt,  in  the  entire 
ovum,  is  in  the  adult  probably  located  in  the  blood-formino-  and 
blood-depurating  organs,  among  which  the  liver  holds  the  most 
important  place.  It  is  no  argument  against  this  view  that  the 
liver  is  not  the  part  of  the  body  most  often  affected  with 
primary  cancer,  for  neither  is  it  the  usual  seat  of  the  local 
explosions  of  gout. 

The  facts  and  arguments  which  I  have  now  brouo-ht  under 
your  notice  have  led  me  to  the  conclusion  that  functional  de- 
rangement of  the  liver,  by  interfering  Math  the  normal  disinte- 
gration of  albuminous  matter,  and  by  the  production  of  peccant 
substances  which  are  not  readily  eliminated  and  which  there- 
fore accumulate  in  the  system,  may,  in  the  long  run,  lead  to 

many  of  the  most  serious  maladies — both  acute  and  chronic 

to  which  our  race  is  subject.     I  shall  now  proceed  to  consider 

'  Todd  and  Bowman,  Physiology  of  Man,  1856,  vol.  ii.  p.  264. 
pp  2 


580  FUNCTIONAL    DERANGEMENTS    OP    THE    LIVER.  i.rct.  xv. 

certain  symptoms,  indicatiiif^  derangement  of  the  different 
physiological  systems,  but  not  constituting  distinct  diseases, 
which  appear  also  to  result  from  functional  disorder  of  the 
liver. 

IV.     Derangements  of  the  Organs  of  Digestion. 

1.  The  Tongue. — It  is  well  to  remember  tliat  there  may  be 
considerable  functional  derangement  of  the  liver  and  yet  the 
tongue  may  be  perfectly  clean  and  normal,  or  at  most  only 
slightly  coated  in  the  morning  ;  but  in  many  cases,  and  par- 
ticularly if  the  derangement  be  of  old  standing,  the  tongue 
presents  the  appearances  commonly  described  as  characteristic 
of  '  atonic  dyspepsia.'  It  is  large,  pale,  and  flabby,  and  in- 
dented by  the  teeth  at  the  edge  of  the  anterior  third,  while  its 
surface  is  white,  and  the  papillae  often  elongated,  so  as  to  pro- 
duce a  pilous  appearance.  If  the  liver  be  somewhat  congested, 
with  these  appearances  we  may  often  observe  the  fungiform 
papillte  on  the  tip  and  edges  larger  and  redder  than  natural. 
In  other  cases,  and  especially  when  there  is  at  the  same  time 
more  or  less  gastric  catarrh,  the  whole  surface  of  the  tongue  is 
uniformly  covered  with  a  thick  fur,  sometimes  whitish,  but 
occasionally  of  a  yellowish  or  brownish  tint.  According  to  Sir 
James  Paget,  psoriasis  of  the  tongue,  dif&cult  to  distinguish 
from  syphilitic  psoriasis,  occasionally  results  from  gout.' 

2.  The  Appetite  may  be  excellent,  although  there  is  great 
functional  derangement  of  the  liver  with  litha^mia,  so  that  the 
patient  is  often  tempted  to  eat  what  he  knows  from  experience 
to  disa<^ree  with  him.  But  when  the  flow  of  bile  into  the  bowel 
is  deficient,  the  appetite  is  often  bad,  and  there  may  be  a 
loathing  of  fat  and  of  greasy  articles  of  diet.  In  cases  which 
are  not  uncommon,  where  there  is  much  functional  derange- 
ment of  the  liver  in  conjunction  with  hepatic  congestion  and 
chronic  gastric  catarrh,  there  may  be  a  loathing  of  all  food 
excepting  alcoholic  stimulants,  which  increase  the  existing 
mischief,  but  which,  as  I  have  already  stated,  may  lead  to  the 
accumulation  of  large  quantities  of  fat. 

3.  A  Bitter  Taste  is  not  unfrequently  complained  of  by 
persons  who  are  the  subjects  of  jaundice ;  but  the  symptom  is 
not  due  to  the  presence  in  the  blood  of  bile-pigment,  which  is 
tasteless,  but  may  be  owing  to  its  containing  taurocholic  acid, 

'  Bht.  Med,  Journ.  1875,  i.  727- 


I.ECT.  XV.  DERANGEMENTS    OF    DIGESTION.  $8 1 

which  is  intensely  bitter,  or  some  abnormal  product  of  dis- 
integrated albumen.  This  may  explain  why  many  patients 
suflfering  from  functional  derangement  of  the  liver,  but  who 
have  not  a  trace  of  jaundice,  often  complain  of  a  bitter,  or 
sometimes  a  '  coppery,'  taste  in  the  mouth,  especially  in  the 
morning. 

4.  Dyspepsia. — "Flatulence is  a  common  symptom  of  functional 
derangement  of  the  liver.  It  is  one  of  the  most  frequent  results 
of  a  deficient  flow  of  bile  into  the  bowel,  and  when  the  bile-duct 
is  completely  obstructed  it  is  rarely  absent.  3t  is  likewise  a 
common  symptom  in  lithsemia,  where  there  is  often  also  a 
deficiency  of  bile  in  the  bowel,  and  in  all  cases  where  the  cir- 
culation through  the  liver  is  torpid.  In  all  these  cases,  in  conse- 
quence of  a  deficiency  in  the  bowels  of  bile,  which,  as  we  have 
seen,  is  endowed  with  antiseptic  properties,  the  intestinal  con- 
tents undergo  fermentation  and  gas  is  generated,  which  accumu- 
lates in  the  bowels,  the  distension  being  usually  greatest  from 
one  to  three  hours  after  a  meal.  Acidity  is  another  common 
symptom  in  lithsemic  patients.  Many  articles  of  diet  habitually 
disagree  with  such  patients  or  render  them  '  bilious.'  They 
awake  next  morning  with  a  dry  or  clammy  tongue,  a  bitter 
taste,  frontal  headache  or  vertigo,  cramps,  or  pains  in  the 
knuckles. 

5.  Constipation  or  Diarrhcea. — In  a  large  number  of  cases  of 
functional  derangement  of  the  liver  with  lithsemia  the  bowels 
are  more  or  less  constipated ;  there  is  probably  a  deficiency  in 
the  quantity  of  bile  which  passes  down  the  bowel,  and  therefore 
a  want  of  the  normal  stimulus  to  peristaltic  action.  The  motions 
are  either  unusually  pale,  or,  from  long  detention  in  the  bowel 
and  the  action  upon  them  of  the  intestinal  juices,  they  become 
black  and  lumpy.  The  latter  condition  is  often  associated  with 
much  depression  of  spirits,  and  hence  the  '  melancholia '  of  early 
writers  on  medicine. 

But  functional  derangements  of  the  liver  may  be  attended 
by  the  opposite  condition  of  diarrhcea,  or  constipation  and 
diarrhoea  may  alternate.  It  is  generally  assumed  that  this 
diarrhoea  is  due  to  an  increased  secretion  and  discharge  of  bile  ; 
and,  in  fact,  'an  excessive  secretion  of  bile,'  showing  itself  in 
'  copious,  fluid,  alvine  evacuations,  highly  coloured  with  bile, 
often  preceded  by  griping,  by  nausea,  and  sometimes  by  vomiting,' 
is  one  of  the  three  functional  derangements  of  the  liver  described 


582  FTJIS^CTION'AL    DEEANGEMENTS    OF    THE    LIVEK.         lect.  xv, 

by  Dr.  Copland^  and  other  practical  writers.  Dr.  Copland 
ndniitted  that  'excessive  biliary  secretion  is  more  frequently 
inferred  from  circumstances  than  proved  by  unequivocal  evi- 
dence ;'  and,  for  my  own  part,  without  denying  the  possibility 
of  the  biliary  secretion  being  sometimes  excessive  in  quantity 
and  unusually  irritating,  so  as  to  excite  diarrhoea,  my  experience 
has  induced  me  to  adopt  a  different  explanation  for  the  majority, 
at  all  events,  of  the  cases  of  so-called  '  excessive  secretion  of 
bile.'  In  most  of  these  cases  there  is  evidence  of  more  or  less 
congestion  of  the  liver;  the  circulation  through  the  liver  is  im- 
peded, and  there  is  a  general  stagnation  of  blood  in  the  coats  of 
the  stomach  and  bowels.  This  mechanical  stagnation  is  very 
likely  to  become  converted  into  an  active  congestion  or  a 
catarrhal  inflammation  under  the  stimulus  of  irritating  ingesta, 
so  that  even  a  small  quantity  of  such  a  stimulus  as  alcohol  may 
excite  diarrhoea  and  vomiting.  In  many  of  these  cases  of 
'bilious  diarrhcea'  the  stools  contain  much  mucus  as  well  as  bile. 
Erom  what  has  been  stated  in  my  first  lecture,-  it  is  obvious  that 
the  large  quantity  of  bile  discharged  from  the  bowel  in  these 
cases  is  no  certain  sign  of  an  increased  secretion  by  the  liver, 
but  may  be  due  to  a  diminished  absorption,  consequent  on  irrita- 
tion of  the  mucous  surface. 

6.  Vitiated  Stools. — A  '  vitiated  biliary  secretion '  is  one  of 
the  three  functional  derangements  of  the  liver  described  by 
systematic  writers.  Although  there  can  be  no  doubt  that  the 
appearances  of  the  bile  in  the  gall-bladder  after  death  are  subject 
to  great  vai^iations,  too  much  importance  has  perhaps  been 
attached  to  the  characters  of  the  stools  during  life  as  an  index 
of  the  state  of  the  liver.  It  must  be  remembered  that  varia- 
tions in  the  characters  of  the  stools  may  be  the  result  of  func- 
tional derangements  or  structural  disease  of  the  long  tract  of 
bowel  between  the  entrance  of  the  bile-duct  and  the  amis, 
and  may  likewise  depend  on  the  rapidity  or  slowness  with  which 
this  tract  is  traversed  by  the  fseces.  Bearing  in  mind  these 
sources  of  fallacy,  it  maybe  said  that  when  little  bile  is  poured 
into  the  bowel,  the  stools  are  pale  and  unusually  offensive,  unless 
they  be  long  delayed  in  the  bowel,  in  which  case  they  may  be 
dark  and  lumpy;  but  when  there  is  an  excessive  secretion  or 
diminished  absorption  of  bile,  the  motions  are  relaxed  and  liquid, 
and  contain  a  much  larger  quantity  of  bile  than  in  the  normal 
state. 

'  Medical  Dictionary,  ii.  725.  '  Lect.  XIV. 


LECT.  XV.  DERANGEMENTS    OF    DIGESTION.  583 

7.  Intestinal  Hcemorrhage. — Copious  lisemorrliage  from  the 
bowels  is  well  known  to  be  an  occasional  result  of  cirrhosis  and 
of  other  structural  diseases  of  the  liver  which  obstruct  the  portal 
circulation.  I  have  frequently  met  with  it,  however,  where 
there  has  been  obvious  derangement  of  the  liver,  but  no  reason 
to  suspect  stractural  disease.  The  patients  have,  for  the  most 
part,  been  beyond  middle  age ;  and  I  have  known  the  attacks 
occur  repeatedly  in  the  same  person  at  intenrals  of  many  years. 
The  attack  is  usually  preceded  by  a  feeling  of  oppression  and 
heaviness,  or  by  creeping  sensations  and  more  rarely  severe 
neuralgic  pains  suggesting  gall-stones  about  the  liver,  by  pain 
in  the  right  shoulder,  loss  of  appetite,  nausea,  and  furred 
tongue ;  and  the  attack  is  often  followed  by  a  subsidence  or 
cessation  of  these  symptoms.  Great  relief  is  usually  afforded 
by  calomel  or  blue  pill,  with  saline  aperients.  In  the  intervals 
of  the  attacks  the  patients  may  enjoy  good  health,  except  that 
they  have  to  be  careful  as  to  diet.  Not  un frequently  they 
present  the  symptoms  of  the  lithic  acid  dyscrasia,  or  they  are 
subject  to  attacks  of  gout. 

8.  HcBmorrhoids. — In  a  large  proportion  of  persons  who 
suffer  from  hsemorrhoids  the  primary  cause  is  in  the  liver. 
Hsemorrhoids  are-  a  common  result  of  structural  changes  in  the 
liver,  such  as  cirrhosis ;  but  they  are  also  a  frequent  attendant 
of  functional  derangements,  and  especially  of  the  loaded  state 
of  the  liver  so  common  in  lithsemia. 

9.  Hepatic  Pain. — With  the  exception  just  referred  to, 
severe  pain  in  the  liver  is  not  a  common  symptom  of  purely 
functional  derangement  of  the  organ.  It  may  even  be  absent 
when  there  is  advanced  structural  disease,  unless  there  be  in- 
flammation of  the  peritoneal  investment,  or  pressure  upon  a  nerve 
by  some  morbid  growth.  But  in  cases  of  pi-otracted  lithsemia,  a 
sensation  of  weight,  fulness,  tightness,  or  burning  in  the  hepatic 
region  is  not  uncommon  ;  and  when  the  bowels  are  neglected, 
or  the  patient  continues  to  eat  rich  food  and  drink  alcoholic 
stimulants,  the  liver  is  apt  to  become  enlarged  and  congested 
and  then  it  may  be  the  seat  of  actual  pain,  which  is  usually 
increased  after  meals,  or  by  lying  on  the  left  side. 

10.  Jaundice. — In  considering  whether  jaundice  may  result 
from  functional  derangement  of  the  liver,  it  will  be  necessary 
to  enter  somewhat  in  detail  into  its  pathology.  All  cases  of 
jaundice  may  be  referred  to  one  of  two  classes,  viz.  : — 

(1)  Cases  in  which  there  is  a  mechanical  impediment  to  the 


584  FUlSrCTIONAL    DERANGEMENTS    OF    THE    LIVER.         lect.  xv. 

flow  of  bile  into  the  duodenum,  and  where  the  bile  is  in  conse- 
quence retained  in  the  biliary  passages,  and  thence  absorbed 
into  the  blood. 

( 2)  Cases  in  which  there  is  no  impediment  to  the  escape  from 
the  liver  into  the  bowel. 

The  several  causes  of  jaundice  belonging  to  each  of  these 
classes  are  given  in  the  annexed  Table.  (See  Lecture  X.,  pp. 
324,  334.) 


Y.  Derangements  of  the  Nervous  System. 

1.  Aching  Pains  in  the  Limbs  and  Lassitude,  coming  on 
about  an  hour  after  a  full  meal  and  sometimes  associated  with 
an  irresistible  tendency  to  drowsiness,  are  a  very  common 
symptom  resulting  from  hepatic  derangement  with  lithsemia. 
They  are  often  attended  by  flatulence  and  other  indications  of 
atonic  dyspepsia.  In  organic  diseases  of  the  liver,  complaint 
is  often  made  of  a  dull,  heavy,  or  aching  pain  about  the  right, 
and  more  rarely  about  the  left,  shoulder-blade,  which  is  ac- 
counted for  by  the  connection  existing  between  the  branches  of 
the  subclavius  nerve  and  the  phrenic.  Patients  with  lithsemia 
often  complain  of  a  similar  pain. 

2.  Burning  or  Scalding  Patches  in  the  palms  or  soles,  or  in 
other  parts  of  the  body,  are  a  common  cause  of  complaint  by 
gouty  patients,  as  well  as  by  those  who  are  the  subjects  of 
lithEemia  independent  of  gout.  Sometimes  the  skin  over  the 
patch  is  slightly  flushed  ;  more  commonly  nothing  abnormal  is 
to  be  seen.  These  abnormal  sensations  may  be  persistent ;  but 
far  oftener  they  are  transient  and  frequently  recur. 

3.  Neuralgia. — It  is  well  known  that  gouty  persons  are  very 
subject  to  sciatica,  brachial  neuralgia,  and  neuralgia  in  other 
parts.  Indeed,  as  Sir  James  Paget  has  observed,  a  variously 
shifting  neuralgia  in  a  j^erson  of  middle  or  advanced  age,  ought 
always  to  excite  a  suspicion  of  gout.  The  neuralgia  in  these 
cases  is  rapidly  induced  by  errors  in  diet  and  is  very  common 
in  the  parts  of  the  body  which  are  the  favourite  seats  of  gout, 
such  as  the  heel,  the  ear,  the  tongue,  the  palate,  the  fingers,  or 
the  breast. 

In  rare  cases  a  neuralgic  pain  seems  to  occur  in  the  liver 
itself.  Many,  probably  most,  of  the  reported  cases  of  '  neuralgia 
hepatis'  have  probably  been  examples  of  biliary  colic,  where  the 


i,KCT.   XV.         DEEANGEMENTS    OF    THE    NERVOUS    SYSTEM.  585 

stone  has  never  advanced  beyond  the  neck  of  the  gall- bladder 
or  the  cystic  duct,  so  as  to  cause  jaundice.  My  experience 
would  certainly  lead  me  to  doubt  the  purely  neuralgic  character 
of  any  such  attack  in  which  the  pain  is  followed  by  jaundice, 
as  has  happened  in  some  of  the  recorded  cases.  Other  instances 
of  supposed  hepatic  neuralgia  have  probably  been  examples  of 
nephritic  colic  from  renal  calculi,  where  the  pain,  as  I  have 
known  happen,  radiates  horizontally  forwards,  instead  of  taking 
the  usual  direction  downwards  towards  the  pubes.  But,  making 
allowance  for  such  mistakes  in  diagnosis,  a  certain  number  of 
cases  remain,  which  appear  to  be  examples  of  true  neuralgia  of 
the  liver.  Cases  of  this  sort  have  been  described  by  Trousseau,^ 
Anstie,^  and  other  authors,  although  they  have  not  come  under 
my  own  notice  (p.  485).  The  patients  in  these  cases  have  been 
liable  to  sudden  attacks,  often  periodic,  of  severe  pain  in  the  right 
hypochondrium,  and  radiating  thence  to  the  right  shoulder,  with 
tenderness  over  one  or  more  of  the  dorsal  spinous  processes. 
They  have  been  for  the  most  part  of  nervous  temperament,  and 
subject  to  neuralgic  pains  in  other  parts  of  the  body  ;  and  in  most 
instances  the  attacks  have  been  attended  with  great  depression 
of  spirits.  The  cause  of  the  attacks  is  to  be  sought  for  in  a 
general  neuralgic  tendency  rather  than  in  any  disorder  of  the 
liver.  Trousseau,  however,  has  pointed  out  that  hepatic  colic 
from  gall-stones  may  excite  a  true  neuralgia.  After  showing 
how  the  peripheral  irritation  of  a  false  tooth  may  excite  facial 
neuralgia,  he  observes :  '  The  same  thing  obtains  in  hepatic 
colic.  Fearful  pjain  sets  up  suddenly  in  the  pit  of  the  stomach 
and  in  the  region  of  the  gall-bladder  and  of  the  ductus  com^ 
munis  choledochus.  So  far,  there  is  merely  local  pain,  without 
neuralgia,  and  there  is  no  tenderness  on  pressure  of  the  dorsal 
spinous  processes ;  but  after  two  or  three  days  spent  in  acute 
pain,  a  sharp  pain  is  frequently  complained  of  in  the  seventh, 
eight li  and  ninth  intercostal  spaces,  in  the  shoulder,  in  the 
neck,  and  in  the  arm  on  the  same  side  ;  from  that  time,  neu- 
ralgia exists,  and  the  vertebrae  become  ver}-  tender  on  pressure.'  ^ 
4.  Severe  Cramps  in  the  legs,  abdomen,  and  in  different 
parts  of  the  body  are  common  in  persons  who  are  the  subjects 
of  lithcemia.  They  often  come  on  during  the  night,  and  they 
are  most  common  in  cold  and  damp  weather.     The  late  Sir 

'  Clinical  Lectures,  Sydenham  Society's  Translation,  iv.  236. 

^  Anstie  on  Neuralgia,  1871,  p.  61. 

*  Op.  cit.  Sydenham  Society's  edit.  i.  482. 


586  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVET?.  lect.  xv. 

Charles  Scudamore  remarked  that  in  some  gouty  persons  they 
produced  such  intense  suffering,  as  to  form  the  leading  feature 
of  the  disease.^  Sometimes  they  precede  a  paroxysm  of  articular 
gout.  Two  remarkable  instances  of  this  result  of  litheemia 
have  been  recorded  by  Dr.  Bence  Jones.  The  first  was  that  of 
a  gentleman  aged  40,  who  for  years  had  been  liable  to  constant 
deposits  of  lithic  acid  and  lithates  in  the  urine.  He  then 
became  the  subject  of  attacks  of  violent  pain  in  the  stomach, 
coming  on  from  one  to  five  hours  after  a  late  dinner.  The  pain 
was  intermittently  spasmodic ;  the  most  intense  pain  was 
reached  in  half  a  minute ;  it  then  relaxed,  and  returned  as 
badly  as  before  in  two  minutes.  His  suffering  lasted  about  an 
hour,  when  the  pain  gradually  abated,  leaving  a  tenderness  on 
pressure  and  an  irritability  after  food  for  two  or  three  days. 
After  the  attack,  the  urine  always  deposited  lithic  acid  crystals. 
These  attacks  had  lasted  for  several  months,  but,  under  a 
careful  diet  and  the  use  of  alkalies,  they  entirely  ceased.  The 
second  patient,  who  also  was  the  subject  of  lithsemia,  Avas 
seized  with  violent  cramps  in  the  rectum,  coming  on  six  or 
eight  hours  after  food,  and  lasting  from  half  an  hour  to  an 
hour.  The  attacks  entirely  ceased  under  the  same  treatment 
as  in  the  first  case.^ 

5.  Headache  is  a  not  unfrequent  result  of  hepatic  derange- 
ment. Most  commonly  it  takes  the  form  of  a  dull  heavy  pain 
in  the  forehead,  more  rarely  in  the  occiput,  complained  of  as 
soon  as  the  patient  awakes  in  the  morning,  and  either  speedily 
ceasing  or  lasting  the  greater  part  of  the  day  or  for  several 
days.  Such  headaches  are  common  in  the  subjects  of  lithcemia 
after  any  indiscretion  in  diet,  or  when  the  bowels  are  consti- 
pated. Their  immediate  cause  is  probably  the  presence  in  the 
blood  of  some  abnormal  product  of  albumen-metamorphosis ; 
the  derangement  of  the  liver  is  usually  indicated  by  pain  and 
fulness  in  the  right  hypochondrium,  flatulence,  and  high- 
coloured  urine  loaded  with  lithates ;  and  relief  is  usually 
afforded  by  mercurial  and  saline  purgatives  and  alkaline 
diuretics. 

From  these  headaches  it  is  necessary  to  distinguish  Me^rtw, 
which  unfortunately  is  the  form  of  headache  to  which  the  terms 
'  bilious  '  or  '  sick '  are  still  popularly  applied.  This  is  a 
neuralgia,  which  probably  in  many  cases  is  in  no  way  connected 

'  Nature  and  Cure  of  Gout,  4tli  edit.  1823,  p.  .')32. 

*  Lectures  uu  ratliology  aud  TLorapcutics,  1807,  p.  85. 


LECT.  XV.        DERANGEMENTS    OP    THE    NERVOUS    SYSTEM.  58/ 

with  hepatic  derangement,  tlie  bilious  symptoms  being  the 
result,  and  not  the  cause  of  the  attack,  and  the  presence  of  bile 
in  the  vomited  matter  being,  as  in  sea-sickness,  simply  due  to 
the  urgency  of  the  vomiting.  Although  this  view  was  enun- 
ciated two  centuries  ago  by  Sydenham,  and  since  his  time  has 
been  clearly  set  forth  in  many  medical  writings,  of  which  I 
would  mention,  in  particular,  the  Gulstonian  Lectures  of  the 
late  Dr.  Symonds,  delivered  in  this  College  in  1858,  and  the 
excellent  work  of  our  associate  Dr.  Edward  Liveing,^  recently 
published,  it  is  still  tbe  fashion  to  attribute  these  attacks  to 
'  biliousness,'  or  to  '  an  excess  of  bile  in  the  system.' 

But,  while  fully  admitting  that  megrim  is  in  no  way  con- 
nected with  retained  bile,  T  agree  with  those  authors  who 
believe  that  certain  cases  of  megrim  are  toxic  in  their  origin, 
being  symptomatic  of  gout  and  of  some  other  disorders.  The 
late  Sir  Henry  Holland,  in  his  '  Medical  Notes  and  Eeflections,' 
described  hereditary  periodic  headaches  associated  with  gout, 
and  he  added :  '  In  conformity  with  this  view,  there  is  reason 
to  believe  that  the  kidneys  are  the  excretory  organs  most 
concerned  in  giving  relief  in  these  cases,  and  principally  by 
an  increased  separation  of  lithic  acid  and  its  compounds.'  ^ 
Megrim,  as  Dr.  Liveing  states,  is  sometimes  the  expression  of 
what  is  called  a  latent  gouty  diathesis,  or,  in  other  words,  of 
lithEemia.  A  father  may  have  suffered  from  gout,  and  his  son 
may  become  the  victim  of  megrim.  In  some  patients  megrim 
terminates  when  they  are  attacked  with  gout.  '  So  evidently,' 
observes  Trousseau,  'is  it  (megrim)  a  manifestation  of  the 
gouty  diathesis,  that  articular  gout  and  megrim  are  observed  in 
the  same  person,  the  one  subsiding  on  the  appearance  of  the 
otlier ;  and  that  it  is  often  also  the  only  expression  of  the 
hereditary  tendency  in  subjects  who  are  the  children  of  decidedly 
gouty  parents.'  ^  In  connection  with  these  observations,  I 
would  call  attention  to  certain  cases  which  have  come  under 
my  notice  of  severe  neuralgic  headache  occurring  in  connection 
with  contracted  granular  kidneys,  and  being  sometimes  the 
first  symptom  for  which  the  patient  has  sought  medical  advice. 
The  headache  in  these  cases  also  was  evidently  toxic,  and  in 
one  instance  fatal  coma  followed  the  subcutaneous  injection  of 
a  quarter  of  a  grain  of  morj)hia.     The  headache  has  been  so 

'  On  Megrim  and  some  Allied  Disorders,  London,  1873. 
2  Medical  Notes  and  Reflections,  1839,  p.  288. 
^  Op.  eit.  Sydenham  Society's  edit.  iv.  378. 


588  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.         lect.  xv. 

severe  that  more  than  once  I  have  known  the  case  diagnosed 
as  one  of  cerebral  tumour.  I  have  met  with  these  cases  so 
frequentlj^,  that  I  believe  it  to  be  a  good  rule  to  investigate  the 
condition  of  the  kidneys  in  all  cases  of  neuralgic  headache 
occurring  for  the  first  time  in  persons  of  middle  or  advanced 
age,  before  having  recourse  to  treatment. 

In  this  way,  then,  megrim  may  sometimes  be  traced  to 
hepatic  derangement,  this  derangement  consisting,  not  in  the 
retention  of  bile,  but  in  that  condition  of  liver  which  we  have 
found  to  produce  lithsemia  and  often  to  lead  to  gout;  and,  in 
accordance  with  this  view,  I  have  often  noticed  that  megrim 
has  been  produced  by  particular  articles  of  diet  and  relieved  by 
mercury,  podophyilin,  and  other  remedies  which  unload  the  liver. 

6.  Vertigo,  Tevriporary  Dimness  of  Sight,  Double  Vision,  &c. — 
Sudden  attacks  of  giddiness  are  in  m.a,nj  instances  similar  in 
their  pathology  to  megrim,  and  giddiness  in  certain  patients  re- 
places the  neuralgia.  But  giddiness,  often  associated  with  specks 
or  waviness  before  the  eyes  or  flashes  of  light,  or  double  vision, 
according  to  my  experience,  is  in  a  much  larger  proportion 
of  cases  connected  with  hepatic  derangement,  lithsemia,  and 
gout,  and  follows  the  use  of  certain  articles  of  diet,  such  as 
tea,  champagne,  citron,  etc.  Many  years  ago,  Boerhaave's 
commentator  related  the  case  of  a  man,  who  daring  two 
years  was  always  seized  with  vertiginous  symptoms  when 
he  attempted  to  stand  up.  In  vain  had  the  ablest  practi- 
tioners endeavoured  to  cure  him.  Quite  suddenly  he  had 
an  attack  of  gout,  of  which  disease  up  to  that  date  he  had 
had  no  indication  ;  and  from  that  moment  he  found  himself 
free  from  the  vertigo  to  which  he  had  formerly  been  liable.' 
A  medical  friend  of  my  own  who  has  long  suffered  from  gout, 
as  certainly  as  he  drinks  a  cup  of  tea  or  a  glass  of  champagne, 
is  seized,  often  while  walking  in  the  street,  with  sudden  giddi- 
ness ;  his  head  feels  empty,  and  neighbouring  objects  seem  to 
whirl  round  him  ;  he  does  not  lose  consciousness,  but  he  would 
fall  did  he  not  lay  hold  of  the  railing.  After  a  few  seconds  or 
minutes  the  attack  passes  off,  but  in  some  patients  it  is  more 
persistent.  Another  friend,  who  never  has  had  gout,  but 
whose  urine  is  frequently  loaded  with  lithates,  was  seized  with 
dimness  of  sight  and  giddiness  every  night  while  writing.  He 
took  iron,  quinine,  and  other  tonics,  but  he  got  worse  instead 
of  better.  He  was  advised  to  give  up  his  profession  for  a  time 
'  Trousseau,  op.  cit.  Sydenham  Society's  edit.  iv.  373. 


r.ECT.  XV.  DEEANGEMENTS    OP    THE    NERVOUS    SYSTEM.  589 

and  try  the  effect  of  change  of  air ;  but,  before  taking-  so  serious 
a  step,  he  took  a  few  doses  of  blue  pill,  and  the  symptoms  at 
once  and  permanently  disaj)peared.  A  third  patient  under  uiy 
care,  who  for  years  had  been  subject  to  lithsemia,  but  never  had 
gout,  would  be  suddenly  seized,  while  writing,  with  dimness  of 
sight  and  specks  floating  before  the  eyes,  or  even  with  complete, 
but  temporary,  blindness  of  one  eye.  Here  also  iron  and 
quinine  disagreed,  but  the  symptoms  were  removed  by  remedies 
directed  against  the  liver.  Many  writers  have  referred  attacks 
such  as  those  which  I  have  now  described  to  derangements  of 
the  stomach.  Trousseau,  for  example,  who  has  described  them 
under  the  designation  of  '  vertigo  a  stomacho  Iseso,'  ^  speaks  of 
them  as  associated  with  epigastric  pain  increased  by  food,  flatu- 
lence, acid  eructations,  and  vomiting  of  glairy  mucus ;  but  he 
admits  that  the  gastric  derangement  in  which  the  vertigo  is 
supposed  to  originate  may  not  show  itself,  and  this  admission 
certainly  accords  with  my  experience.  On  the  other  hand,  the 
circumstance  of  the  frequent  association  of  the  vertigo  with 
gout  or  lithsemia,  and  the  fact  that  alkalies  and  aperients, 
which  are  the  best  remedies  for  these  conditions,  are  also  the 
remedies  most  likely  to  prevent  a  recurrence  of  the  attacks  of 
vertigo,  make  it  probable  that  this  has  a  toxic  origin  and  that 
the  liver  is  the  organ  mainly  at  fault. 

7.  Convulsio7is. — In  January  of  the  present  year  (1874)  I 
saw  a  gentleman,  about  58  years  of  age,  suffering  from  cirrhosis 
of  the  liver.  He  had  all  his  life  been  addicted  to  the  pleasures 
of  the  table,  and  had  suffered  from  hepatic  derangements  as 
long  as  he  could  remember.  Six  years  ago,  he  became  subject 
to  severe  spasmodic  twitchings  in  his  legs,  followed  on  three 
occasions  by  several  epileptiform  seizures.  Shortly  after  the 
last  fit  he  had  his  first  attack  of  gout,  and  since  then,  he  had 
suffered  repeatedly  from  the  gout,  but  there  had  been  no  return 
of  the  convulsions  or  of  the  muscular  twitchings.  There  was 
no  evidence  of  renal  disease.  Many  similar  cases  are,  I  believe, 
on  record.  For  example.  Van  Swieten  mentions  the  case  of  a 
man  who  had  violent  abdominal  pains  accompanied  b}'^  delirium 
and  general  trembling,  and  subsequently  a  severe  attack  of 
epilepsy.  From  that  date  he  had  repeated  attacks  01  gout,  but 
no  return  of  the  nervous  symptoms.^  Several  similar  cases  are 
related  by  Garrod.     One  gentleman  had  been  liable  to  frequent 

'  Op.  cit.  Sydenham  Society's  edit.  iii.  537. 
«  lb.  iv.  379. 


590  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.  i.ect.  xv. 

epileptic  attacks  from  20  to  52  years  of  age.  He  tlien  had  for 
the  first  time  a  severe  attack  of  gout  in  one  big  toe ;  from  52 
to  92,  when  he  died,  he  had  frequent  recurrences  of  gout,  but 
no  epileptic  attacks.  In  another  case  of  '  gouty  epilepsy '  Dr. 
Garrod  found  lithic  acid  in  the  blood. ^ 

8.  Mania,  like  epilepsy,  is  an  occasional  result  of  lithjBmia, 
ceasing  suddenly  and  permanently  on  the  advent  of  an  attack 
of  gout. 

9.  Paralysis. — I  have  repeatedly  met  with  patients  who  have 
complained  of  numbness,  tingling  and  pricking  sensations — the 
feeling  as  if  the  part  were  asleep — or  a  feeling  of  coldness 
or  creeping  in  the  extremities  on  both  sides,  or  only  on  one. 
These  symptoms  may  last  for  months  or  years,  and  may  be 
associated  with  headache,  nausea,  and  depression  of  spirits. 
They  often  cause  needless  alarm  by  exciting  the  suspicion  that 
paralysis  is  imminent ;  but,  if  associated,  as  they  often  are,  with 
lithsemia,  oxaluria,  or  other  evidence  of  hepatic  derangement, 
they  may  entirely  and  permanently  disappear  under  the  use  of 
calomel,  saline  aperients,  alkalies,  and  attention  to  diet. 

10.  Noises  in  the  Ears  are  common  symptoms  in  gout  ^  and 
also  in  litheemia  independent  of  gout.  One  patient  has  the 
feeling  of  a  strong  wind  blowing  into  the  ear ;  another  compares 
ihe  noise  to  that  of  flowing  water,  or  of  singing  or  buzzing ; 
while  in  another  the  sounds  have  a  pulsating  character,  the 
sounds  corresponding  to  those  of  the  heart. 

11.  Sleeplessness  may,  of  course,  arise  from  many  diflPerent 
causes,  but  one  of  its  causes  is  that  derangement  of  the  liver 
which  produces  lithsemia.  When  this  is  the  case,  the  patient 
is  often  heavy  and  drowsy  after  a  fall  meal,  and  he  may  fall 
asleep  at  once  on  retiring  to  rest ;  but,  after  one,  two,  three, 
or  four  hours,  he  awakes,  and  then  he  either  lies  awake  for 
hours,  or  he  is  constantly  falling  asleep,  dreaming,  or  having 
the  nio-htmare  and  awaking — four  or  five  times  or  even  oftener 
in  the  course  of  one  hour — until  the  morning  comes,  when  he 
drops  into  a  quiet  sleep  of  an  hour  or  more,  or  be  is  obliged  to 
get  up  tired  and  irritable.  This  sleeplessness,  like  the  vertigo 
we  have  already  considered,  is  often  induced  by  j^articular 
articles  of  diet,  or  by  some  unwholesome  combination  of  them. 
What  will  excite  headache,  giddiness,  or  disorders  of  the  circula- 

'  On  Gout,  3r(I  edit.  1876,  p.  160. 
*  Scudamore,  op.  cit.  p.  376. 


LECT.  XV.         DERANGEMENTS    OF    THE    NEEVOUS    SYSTEM.  591 

tion  in  some  patients  will  in  another  cause  sleeplessness. 
Sometimes,  however,  this  symptom  will  occur  when  the  patient 
is  most  careful  as  to  diet.  What  is  important  also  to  note  is, 
that  in  most  of  these  cases  there  are  no  obvious  symptoms  of 
gastric  dyspepsia ;  the  appetite  may  be  good — too  good,  in  fact ; 
the  bowels  may  be  regular;  and  there  may  be  no  pain,  flatu- 
lence, or  other  discomfort  after  meals  ;  but  there  will  be  found 
an  unusual  tendency  to  the  deposit  of  lithates  in  the  urine,  and 
very  often  other  phenomena  of  a  so-called  gouty  diathesis. 
This  form  of  sleeplessness  was  described  a  century  ago  by 
CuUen,  the  distinguished  nosologist,  in  these  words  :  '  Persons 
who  labour  under  a  weakness  of  the  stomach,  as  I  have  done 
for  a  great  number  of  years  past,  know  that  certain  foods,  with- 
out their  being  conscious  of  it,  prevent  sleeping.  So  I  have 
been  awakened  a  hundred  times  at  two  o'clock  in  the  morning 
when  I  did  not  feel  any  particular  impression ;  but  I  knew  that 
I  had  been  awaked  by  an  irregular  operation  in  that  organ,  and 
I  have  then  recollected  what  I  took  at  dinner,  which  was  the 
cause  of  it.  Dr.  Haller  is  liable  to  the  same  complaint ;  and 
in  his  larger  work  especially,  he  gives  the  particulars  of  his 
own  case.'  ^  The  aiFection  has  also  been  well  described  by  Dr. 
Dyce  Duckworth  in  some  excellent  observations  on  different 
forms  of  sleeplessness  recently  published.^  It  is,  however,  a 
form  of  sleeplessness  not  generally  understood,  and  harm  is 
often  done  to  patients  suffering  from  it  by  the  administration 
of  opiates  and  other  soporifics,  in  ignorance  of  its  real  cause. 
Yery  often  the  symptom  will  be  greatly  relieved,  if  not  entirely 
removed,  by  careful  attention  to  diet,  and  particularly  by  mode- 
ration in,  or  abstinence  from,  wine  ;  and,  in  some  cases,  a  dose 
of  carbonate  of  soda  when  the  patient  goes  to  bed,  or  when  he 
first  awakes,  is  of  service.  Some  j)atients  with  this  form  of 
sleeplessness  have  told  me  that  they  never  sleep  so  well  as  after 
a  dose  of  calomel  or  blue  pill. 

12.  Depression  of  Spirits. — The  influence  of  the  liver  upon 
the  animal  spirits  has  been  recognised  by  medical  writers  in  all 
ages.  To  the  belief  in  the  existence  of  such  an  influence  may 
be  traced  the  origin  of  such  terms  as  HyiDochondriasis  and 
Melancholia.  Although  it  is  not  contended  that  the  morbid 
states  of  mind,  to  which  at  the  present  day  we  apply  these 
terms,  have  their  origin  in  the  liver,  they  are  unquestionably 

1  Institutions  of  Medicine,  ]  770. 

2  British  Medical  Journal,  DeceraLer  27,  1873. 


592  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.  lect.  xv. 

ill  many  instances,  accompanied  and  aggravated  by  derange- 
ments of  this  organ;  and  it  is  equally  true  that,  independently 
of  either  hypochondriasis  or  melancholia,  persons  with  functional 
derangement,  or  structural  disease,  of  the  liver  are  subject  to 
fits  of  great  depression  of  spirits  and  often  groundless  fears  of 
impending  danger,  which  cease  when  the  liver  is  restored  to  its 
normal  istate. 

13.  Irritability  of  Tern'per  is  another  common  symptom  of 
functional  derangement  of  the  liver,  and  is  sometimes  the  first 
indication  of  anything  wrong.  A  man  who  has  previously 
borne  the  crosses  of  life  with  equanimity  and  been  amiable  to 
those  about  him  gradually  becomes  disconcerted  by  trifles  ;  his 
mind  broods  upon  them  ;  and  he  makes  all  around  him  unhappy 
and  himself  the  most  miserable  of  all.  His  relatives  perceiving 
no  other  sign  of  indisposition,  and  failing  to  recognise  the  true 
cause,  too  often  put  down  the  ebullitions  of  temper  to  some- 
thing mentally  or  morally  wrong,  to  moral  depravity,  or  failure 
to  make  any  mental  effort ;  but  remedial  measures  calculated 
to  restore  the  liver  to  healthy  action,  if  resorted  to  in  time,  will 
often  remove  the  irritability,  and  either  the  patient's  improve- 
ment under  such  treatment,  or  an  attack  of  gout,  reveals  the 
cause  of  the  patient's  ba,d  temper.  In  his  '  Psychological 
Inquiries,'  the  late  Sir  Benjamin  Brodie  thus  speaks  of  a  patient 
v»'ith  a  superabundance  of  lithic  acid  in  the  blood  :  '  Uncomfort- 
able thoughts  are  presented  to  his  mind  :  he  becomes  fretful  and 
peevish,  a  trouble  to  himself,  and,  if  he  be  not  trained  to  exer- 
cise a  moral  restraint  over  his  thoughts  and  actions,  a  ti'ouble 
to  everyone  about  him.  After  a  while,  the  poison,  as  it  were, 
explodes  :  he  has  a  severe  attack  of  gout  in  his  foot ;  he  is 
placed  on  a  more  prudent  diet ;  the  system  is  relieved  of  the 
lithic  acid  by  which  it  was  poisoned.  Then  the  gout  subsides ; 
happy  and  cheerful  thoughts  succeed  those  by  which  the  patient 
was  previously  tormented,  and  these  continue  until  he  has  had 
the  opportunity  of  relapsing  into  his  former  habits,  and  thus 
earning  a  fresh  attack  of  the  disease.'  ^ 

14.  Cerebral  Symptoms  and  the  Ti/phoid  State. — It  is  well 
known  that  restlessness,  delirium,  stupor,  coma,  subsultus,  tre- 
mors, convulsions,  a  dry,  brown  tongue,  and  other  phenomena 
of  the  '  typhoid  state,'  are  apt  to  supervene  in  certain  cases  of 
advanced  disease  of  the  liver,  whether  attended  by  jaundice  or 
not.     These  symptoms  have  been  usually  attributed  to  a  sup- 

>  Second  edit.  1855,  p.  73. 


LECT.  XV.  DEEANGEMENTS    OF   THE    NERVOUS    SYSTEM.  593. 

pressed  secretion  of  bile.  But  the  assumption  that  the  elements 
of  the  bile  are  preformed  in  the  blood,  and  are  merely  separated 
from  the  blood  by  the  liver,  we  have  already  found  to  be  devoid 
of  foundation  ;  and  we  have  also  found  that  bile  is  far  from  being, 
as  commonly  supposed,  a  deadly  poison,  and  that  its  presence 
in  the  blood,  even  to  saturation,  does  not  give  rise  to  cerebral 
symptoms.  The  cerebral  symptoms  referred  to  are  often  most 
severe  when  the  jaundice  is  slight,  or  when  there  is  none  ; 
and  they  are  readily  accounted  for  by  the  knowledge  of  the 
disintegrating  function  which  the  liver  is  now  known  to  per- 
form. Wheji  this  function  of  the  liver  is  arrested  or  seriously 
impaired,  urea  is  no  longer  eliminated  in  sufficient  quantity 
by  the  kidneys,  lithic  acid  and  deleterious  products  of  dis- 
integrating albumen  even  less  oxydised,  such  as  leucin  and 
ty rosin  and  perhaps  others  with  which  we  are  as  yet  imper- 
fectly acquainted,  accumulate  in  the  blood  and  tissues  ;  and 
the  result  is  the  development  of  symptoms  of  blood-poison- 
ing similar  to  those  which  arise  when  the  kidneys  are  unable 
to  eliminate  the  products  of  albumen-degeneration  owing  to 
disease  of  their  own  structure,  or  to  an  excessive  formation  of 
urea  and  other  products  as  happens  in  many  febrile  diseases. 
In  acute  atrophy,  for  example,  the  structure  of  the  liver  is  de- 
stroyed and  its  functions  arrested ;  leucin  and  tyrosin  take  the 
place  of  urea  in  the  urine  and  are  also  found  in  large  quantity 
in  the  liver,  spleen,  and  kidneys  ;  while  cerebral  symptoms  and 
the  typhoid  state  are  prominent  features  of  the  disease. 


QQ 


594  FUNCTIONAL    DEKANGEMBNTS    OF    THE    LIVER.        lect.  xvi. 


LECTURE   XVI. 

THE  CROONIAN  LECTURES  ON  FUNCTIONAL  DERANGE- 
MENTS OF  THE  LIVER. 

VI.  DERANGEMENTS  OF  THE  ORGANS  OF  CIRCULATION.  1.  PALPITATIONS  AND  FLUT- 
TEKINGS  OF  THE  HEAKT  ;  2.  EXAGGERATED  PULSATION  OF  THE  LARGE  ARTERIES;  3. 
IRREGULARITIES  AND  INTERMISSIONS  OF  THE  PULSE  ;  4.  FEEBLE  CIRCULATION ;  5. 
AN.EMIA  ;  6.  ANGINA  PECTORIS  ;  7-  VENOUS  THROMBOSIS.— VII.  DERANGEMENTS  OF 
ORGANS  OF  RESPIRATION.  1.  CHRONIC  CATARRH  OF  FAUCES;  2.  BRONCHITIS;  3. 
SPASMODIC  ASTHMA. — VIIX.  DERANGEMENTS  OF  THE  GENITO-URINARY  ORGANS.  1. 
DEPOSITS  OF   LITHIC    ACID    AND    LITHATBS    IN    URINE  ;    2.  RENAL  CALCULI  ;    3.    DISEASES 

OF  KIDNKYS  ;    4.  CYSTITIS  ;  6.  URETHRITIS  ;    6.    CHORDEE  ;    7-  ORCHITIS. IX.  ABNORMAL 

CONDITIONS  OF  THE  SKIN.     1.    ECZEMA,  LEPRA,  PSORIASIS,  AND  LICHEN;    2.    URTICARIA  ; 

3.  BOILS    AND    carbuncles;     4.     PIGMENT-SPOTS  ;    5.     xanthelasma;    6.    PRURITUS. 

C.  CAUSES  OF  FUNCTIONAL  DEIiANGEMENTS  OF  THE  LIVER. 1.  SECONDARY.   1.  STRUCTURAL 

DISEASES  OF  THE  LIVER  ;  2.  DISORDERS  OF  STOMACH  AND  BOWELS  ;  3.  DISEASES  OF 
THE  HEART  AND  LUNGS;  4.  PY-^REXIA. II.  PRIMARY. 1.  ERRORS  IN  DIET;  2.  DEFI- 
CIENT SUPPLY  OF  OXYGEN  ;  3.  HIGH  TEMPERATURE  ;  4.  NERVOUS  INFLUENCES  ;  0. 
CONSTITUTIONAL  PECULIARITIES  ;  6.  POISONS. — D.  TREATMENT  OF  FUNCTIONAL  DE- 
RANGEMENTS   OF    THE  LIVER.        1.    DIET;      2.    FREE  SUPPLY   OF    OXYGEN;    3.    DILUENTS; 

4.  BATHS  ;  5.  APERIENTS — CHOLAGOGUBS  ;  6.  ALKALIES  ;  7.  CHLORINE,  IODINE,  BROMINE, 
AND  THEIR  salts;    8.  MINERAL  ACIDS;    9.  TONICS  ;   10.  OPIUM.       CONCLUDING  REMARKS. 

Mr.  President,  Fellows  of  the  College,  and  Gentlemen, 
— lu  my  last  lecture  I  considered  some  of  the  more  important 
diseases  and  symptoms  resulting  from  abnormal  disintegration 
of  albuminous  matter  in  the  liver.  I  have  still  to  refer  to 
certain  derangements  of  the  organs  of  circulation  and  respira- 
tion, and  to  abnormal  states  of  the  skin  traceable  to  the  same 
cause.  I  shall  then  mention  some  of  the  chief  causes  of 
functional  derangements  of  the  liver,  and  conclude  the  lecture 
by  a  brief  sketch  of  the  principal  rules  for  treatment  of  these 
derangements. 

VI.  Derangements  of  the  Organs  of  Circulation. 

].  PdJpif.ations  and  Flutteririgs  of  the  Heart. — Indigestion 
Ikas  long  been  regarded  as  one  of  the  causes  of  palpitation  in- 
dependent of  organic  disease  of  the  heart.     Many  patients  with 


XECT.  XTi.  DERANGEMENTS    OF    CIllCULATION.  595 

this  functional  derangement  of  the  heart  describe  their  sensa- 
tions as  that  of  a  transient  fluttering  rather  than  a  continuous 
palpitation ;  and  when  this  feeling  of  fluttering  comes  to  be 
investigated,  it  usually  turns  out  to  be  produced  by  a  strong 
thump  of  the  apex  of  the  heart  following  one  or  more  weaker 
beats  or  a  decided  stop.  In  some  of  these  cases  of  palpitation 
and  fluttering  a  prominent  symptom  of  the  indigestion  is 
flatulence ;  and  then  the  common  explanation  of  the  cardiac 
symptoms  is,  that  they  are  due  to  the  pressure  upon  the  heart 
of  the  distended  stomach  and  bowels ;  and  this  explanation 
receives  support  from  the  fact  that,  on  the  removal  of  the 
flatulence,  the  ctirdiac  symptoms  are  often  relieved  or  cease. 
But  in  other  of  these  cases  the  flatulence  may  be  entirely 
removed,  while  the  cardiac  symptoms  remain ;  while  in  others 
there  is  not  the  slightest  evidence  of  flatulence,  and  still  the 
cardiac  symptoms  are  removed  by  remedies,  such  as  alkalies 
and  aperients,  calculated  to  improve  the  condition  of  the  liver. 
It  seems  probable,  therefore,  that  in  some,  if  not  in  manj^, 
cases,  when  flatulence  and  palpitations  coexist,  they  do  not 
stand  in  the  relation  of  cause  and  effect,  but  are  both  the 
result  of  a  common  cause.  Palpitations  and  still  more  flutter- 
ings  of  the  heart  are  particularly  common  in  gouty  people, 
whether  they  suffer  from  dyspeptic  symptoms  or  not.  Everyone 
present  must  have  met  with  cases  of  the  sort.  Scudamore 
relates  cases  in  which  patients  suffered  from  severe  paipita- 
tions  for  six  months  without  any  relief  from  medicine ;  but,  on 
the  occurrence  of  a  fit  of  gout,  the  palpitations  suddenly  and 
entirely  ceased.'  Dr.  Garrod, in  his  work  on  Gout,  remarks: 
'  One  of  the  most  common  symptoms  produced  by  a  gouty  state 
of  the  system  is  palpitation  of  the  heart,  often  accompanied  by 
irregularity  of  its  rhythm,  and  occasionally  with  pulsa,tion  of 
some  of  the  larger  arteries.  In  the  majority  of  these  cases, 
the  condition  is  secondary  to  dyspepsia,  but  at  times  it  may  be 
directly  excited  by  the  impure  condition  of  the  blood ;  and  I 
have  notes  of  some  cases  in  which  no  organic  mischief  could  be 
discovered  in  the  heart,  nor  any  sign  of  indigestion,  and  the 
symptoms  ceased  on  the  occurrence  of  gout  in  the  joints.'  ^ 
These  cardiac  symptoms  are  also  very  common  in  persons  who 
are  the  subjects  of  lithsemia  or  oxaluria,  but  who  never  have 
gout.     They  are  often  the  first  symptoms  to  draw  the  patient's 

'   Op.  cit.  pp.  16,  98,  374. 

^  Nature  aud  Treatment  of  Gout,  1859,  p.  610. 
Q  Q  2 


596  FUNCTIONAL    DERANGEMENTS    OP    THE    LIVER.        lect.  xti. 

notice  to  the  fact  that  his  health  is  not  what  it  ought  to  be ; 
they  cause  great  depression  of  spirits  ;  and  very  often  they  are 
aggravated  by  injudicious  treatment,  and  especially  by  the  use 
of  iron,  which  may  seem  to  be  indicated  by  the  patient's  ansemic 
aspect,  but  which  is  rarely  tolerated  until  the  liver  has  been 
brought  into  a  healthy  state  by  alkalies,  aperients,  and  attention 
to  diet.  Although  in  the  cases  now  referred  to  the  cardiac 
symptoms  result  from  pneumogastric  irritation  by  a  poison  in 
the  blood,  the  fact  already  referred  to  must  not  be  lost  sight  of, 
that  this  same  morbid  state  of  blood  may  ultimately  lead  to 
degeneration  of  the  muscular  wall  of  the  heart,  or  to  disease  of 
the  aortic  valves  (see  p.  576). 

2.  Exaggerated  Pulsation  of  the  Large  Arteries. — Dr.  Matthew 
Baillie,  in  a  communication  made  to  this  College  on  December 
2,  1812,  was  the  first  to  call  attention  to  cases  of  increased 
pulsation  of  the  aorta  in  the  epigastric  region,  simulating 
aneurism,  but  in  some  instances  lasting  twenty -five  years  or 
longer,  and  the  result  merely  of  '  imperfect  digestion  with  an 
irritable  constitution.'  ^  This  exaggerated  pulsation,  not  only 
of  the  aorta,  but  of  other  arteries,  independent  of  either  con- 
tracted kidney  or  aortic  regurgitation,  is  now  well  known,  and 
one  cause  of  it  appears  to  be  a  morbid  state  of  blood  resulting 
from  derangement  of  the  liver  and  often  associated  with  gout. 
Scudamore  relates  cases  of  palpitations  in  the  head  occurring 
in  persons  aftlicted  with  bilious  derangement  and  gout,  and 
likewise  the  case  of  a  gentleman  who  had  gout  and  bilious 
derangement,  and  who  suffered  alternately  from  palpitation  of 
the  heart  and  pulsation  of  the  aorta  in  the  epigastric  region.^ 
Garrod  also  speaks  of  an  irritable  state  of  the  aorta  and  pulsa- 
tion of  the  larger  arteries  as  occasionally  resulting  from  gout.^ 
The  undue  pulsation  in  these  cases  is  often  subdued  by  treat- 
ment directed  against  the  liver. 

3.  Irregularities  and  Intermissions  of  the  Pulse. — An  intermit- 
ting pulse,  which  may,  or  may  not,  be  attended  by  the  sensation 
of  fluttering  of  the  heart  already  referred  to,  results  from  a 
variety  of  causes,  of  which  the  principal  are  these : — 

a.  Valvular  and  other  diseases  of  the  heart.  In  organic 
diseases  of  the  heart,  however,  irregularity  of  the  rhythm  is  more 
common  than  decided  intermission. 

'  Medical  TratLsaclions,  published  Ly  the  College  of  Physicians,  1813,  vol.  iv. 
p.  274. 

-  Op.  cit.  p.  08.  *  Op.  cit.  pp.  510,  Oil. 


lECT.  XVI.  DEEANGEMENTS    OF    CIRCULATION.  597 

h.  A  weakened  or  unduly  irritable  state  of  tlie  nervous 
system,  such  as  that  which  often  occurs  in  old  age,  or  sometimes 
appears  to  be  constitutional,  or  those  which  are  induced  by 
fevers,  delirium  tremens,  hysteria,  protracted  want  of  sleep, 
anxiety,  etc. 

c.  Morbid  states  of  the  blood  associated  with  gout  or 
lithsemia,  or  with  other  evidence  of  hepatic  derangement.  It 
has  been  the  fashion  to  attribute  the  intermission  in  these  last 
cases  to  pneumogastric  irritation  by  gastric  dyspepsia  or  flatu- 
lence ;  but,  just  as  we  found  in  vertigo  and  palpitation,  there 
is  very  often  neither  flatulence  nor  other  evidence  of  gastric 
derangement ;  and  my  experience  has  led  me  to  the  conclusion 
that  in  most  of  these  cases  the  pneumogastric  irritation  has  a 
toxic  origin,  or  is  due  to  the  presence  in  the  blood  of  some 
morbid  material  resulting  from  derangement  of  the  liver. 
What  this  material  is  we  do  not  with  certainty  know.  It  is  not 
uncommon  for  the  pulse  to  become  very  slow,  or  even  to  be  irre- 
gular or  to  intermit,  in  jaundice.  These  symptoms  do  not  appear 
to  be  due  to  the  presence  of  bile-pigment  in  the  blood,  for  in 
many  cases  of  jaundice  they  are  absent;  but  the  experiments 
made  by  Eohrig,  Legg,  and  others  have  shown  that  the  bile-acids 
paralyse  the  heart  and  retard  its  action,  while  bile-pigment  has 
no  such  effect.^  It  is  possible,  then,  that  slowness  and  inter- 
mission of  the  pulse  may  be  caused  by  the  presence  in  the 
blood  of  unchanged  bile-acids,  even  in  cases  where  there  is  no 
jaundice ;  but  probably  another  cause  of  the  intermission  is 
some  product  of  albuminous  disintegration,  inasmuch  as  it  is  so 
commonly  met  with  in  connection  with  lithsemia  or  gout,  and 
as  it  is  often  entirely  removed  by  blue  pill,  saline  aperients, 
alkalies,  and  attention  to  diet.  A  notable  fact  in  these  cases  is 
that  the  tendency  of  the  pulse  to  intermit  is  usually  greatest 
when  the  patient  is  at  rest,  and  is  diminished  or  ceases  on  his 
taking  exercise.  As  in  the  case  of  vertigo  or  sleeplessness,  the 
intermission  may  be  excited  by  particular  articles  of  diet.  It 
may  last  for  many  years,  during  which  the  patient  may  enjoy 
very  fair  health  and  be  capable  of  considerable  exertion.  I 
lately  saw  a  gentleman,  aged  eighty,  who  had  had  an  intermit- 
ting pulse  for  upwards  of  fifty  years.  He  had  suifered  from 
gout  and  dyspepsia,  but  in  his  eightieth  year  he  could  walk 
long  distances  and  up  moderate  ascents  without  difficulty.  It 
is  also  worth  noting  that  intermission  of  the  pulse  may  last  for 
'  See  Lecture  IX.,  p.  320. 


598  FUNCTIONAL   DERANGEMENTS    OF    THE    LIVER.         lkct.  xvi. 

years,  and  then  entirely  disappear.  Dr.  C  Lasegne  of  Paris, 
who  has  published  an  interesting  memoir  ^  upon  intermitting 
liaise,  thinks  that  it  is  chiefly  met  with  under  two  conditions, 
viz. :  firstly,  as  an  accompaniment  of  some  chronic  general 
morbid  state,  which  is  the  prelude  of  some  more  acute  mis- 
chief, on  the  development  of  which  the  intermissions  may  cease  ; 
and  secondly,  as  the  accompaniment  of  a  general  morbid  state 
consequent  on  the  first  establishment  of  some  local  disease, 
the  general  cachexia  and  the  intermitting  pulse  after  a  time 
disappearing,  although  the  primary  local  disease  remains.  The 
following  case,  communicated  to  me  by  Mr.  Paul  Jackson,  is  a 
remarkable  illustration  of  the  complete  disappearance  of  the 
intermission  after  a  duration  of  several  years,  and  also  of  its 
toxic  origin. 

About  the  year  1838,  Mr.  J.  T.,  then  forty-two  years  of  age, 
of  nervous  temperament,  a  generous  liver,and  subject  to  hepatic 
derangement,  began  to  suffer  from  intermission  of  the  pulse 
and  a  fluttering  sensation  at  the  heart.  He  had  no  dyspnoea 
nor  other  symptom  of  cardiac  disease,  and  there  was  no  abnormal 
cardiac  murmur.  He  saw  a  great  many  physicians,  but  got  no 
relief;  but,  after  upwards  of  three  years,  he  had  a  severe  attack 
of  urticaria,  whereupon  the  intermission  and  the  fluttering 
entirely  and  for  ever  ceased.  He  lived  for  twenty  years  after- 
wards, and,  with  the  exception  of  occasional  attacks  of  gout  and 
of  sudden  vertigo,  he  enjoyed  good  health.  He  died  at  last, 
however,  suddenly,  of  rupture  of  the  heart,  at  the  age  of  sixty- 
five. 

It  may  be  well  to  add  that,  even  when  intermitting  pulse 
coexists  with  valvular  disease  of  the  heart,  it  aj)pears  to  be 
sometimes  due  to  hepatic  derangement  rather  than  to  the 
cardiac  lesion.  Take,  for  example,  aortic  incompetence.  The 
rhythm  of  the  pulse  in  this  lesion  is  usually  regular,  but  in 
rare  instances  it  is  irregular  and  intermitting.  From  the 
supervention  of  this  symptom  the  patient's  condition  is  often 
believed  to  have  become  more  perilous,  and  yet  there  may  be  no 
aggravation  of  the  other  cardiac  symptoms.  The  pulse  may 
become  regulai',  instead  of  more  intermitting,  after  exercise, 
and  the  intermission  may  be  entirely  removed  by  the  same 
remedies  as  are  effectual  when  there  is  no  cardiac  disease.  That 
the  intermission  of  the  pulse  should  be  independent  of  the 

'  Des  Intermittences  Cardiaqucs,  par  le  Dr.  C.  Lasegue,  Arch.  Gen.  de  Med. 
DecemLer  1872. 


LECT.  XVI,  DEEANGEMENTS    OF    CIRCULATION.  5gg 

cardiac  lesion  is  not  surprising,  when  we  remember  that 
atheroma  of  the  arteries,  which  is  the  main  cause  of  aortic  in- 
competence occurring  in  middle  or  advanced  life,^  and  inter- 
mitting pulse  may  both  result  from  the  lithic  acid  dyscrasia. 
The  following  case  is  an  illustration  of  what  I  have  just  stated. 
A  discharged  soldier,  aged  56,  came  under  my  care  in  July 
1873  for  what  appeared  to  be  muscular  or  neuralgic  pains.  He 
was  found  to  have  aortic  incompetence,  but  he  had  never  had 
any  symptom  of  cardiac  disease — pain,  palpitation,  or  dyspnoea — 
and  he  had  been  employed  as  a  porter  in  a  public  institution, 
one  of  his  duties  being  to  carry  heavy  coal-scuttles  up  long 
stairs^  from  which  he  had  apparently  suffered  no  inconvenience™ 
His  pulse  was  quite  regular.  He  was  treated  with  quinine,  but 
he  left  the  hospital  after  some  weeks  not  much  relieved,  and 
returned  to  his  work.  In  December  he  again  came  to  me, 
complaining  of  pain  in  his  right  shoulder  and  constipation  ;  his 
pulse  was  now  very  intermitting,  and  he  had  also  a  frequent 
feeling  of  fluttering  about  his  heart.  He  had  no  other  cardiac 
symptom,  and  on  walking  his  pulse  became  regular.  He  was 
now  treated  with  blue  pill,  colchicum,  aperients,  alkalies,  and 
iodide  of  potassium,  and  in  a  short  time  the  pain  in  the  shoulder, 
the  fluttering,  and  the  intermission  disappeared. 

4.  Feeble  Circulation. — In  cases  of  protracted  hepatic  de- 
rangement, symptoms  of  feeble  circulation,  which  may  be 
independent  of  palpitations  or  irregularities  of  the  pulse,  are 
not  uncommon.  The  patient  complains  of  languor,  debility, 
and  coldness  of  the  extremities.  The  heart  is  found  to  beat 
feebly,  but  to  be  free  from  organic  disease ;  tbere  is  evidence 
of  hepatic  derangement,  and  the  urine  often  deposits  lithates. 
Iron,  quinine,  and  alcoholic  stimulants,  which  are  frequently 
prescribed  for  this  condition,  may  render  the  patient  worse 
instead  of  better,  and  the  surest  way  to  increase  the  streno-th 
of  the  heart  is  to  avoid  alcohol  and  relieve  the  liver. 

5.  Ancemia  (see  page  579). 

6.  Angina  Pectoris. — The  neuralgic  affection  known  as 
angina  pectoris  probably  arises  in  many  dififerent  ways.  One 
cause  appears  to  be  the  lithic  acid  dyscrasia.  It  is  now  many 
years  since  an  English  physician,  Dr.  William  Butter,  described 
certain  cases  of  this  afi'ection  as  diaphragmatic  gout.  The 
patients  had  been  careless  as  to  diet,  and  '  particularly  fond  of 

*  I  do  not  remember  to  hare  met  -witli  interiuitting  pulse  in  cases  of  aortic  in- 
competence of  rheumatic  origin. 


DOO  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.        lect.  xvi. 

the  stronger  malt  liquors ' ;  the  urine  deposited  '  a  copious 
gross  sediment';  and  the  attack  might  terminate  in  a  fit  of 
the  gout.^  Many  writers  have  since  then  described  a  '  gouty 
cardialgia';  and  Trousseau  has  pointed  out  that  certain  cases 
of  angina  pectoris  are  independent  of  any  disease  of  the  heart 
or  great  vessels,  and  are  merely  a  '  manifestation  of  the  gouty 
diathesis.'  ^  jSTot  long  since,  I  saw  a  gentleman,  aged  65,  who 
complained  of  awaking  in  the  night  three  or  four  times  a  week 
with  violent  pain  in  the  cardiac  region,  extending  up  to  the 
left  shoulder  and  down  the  left  arm.  I  could  discover  no  sign 
of  disease  in  his  heart.  He  stated  that,  six  years  before,  he  had 
suffered  for  months  from  similar  attacks,  but  had  recovered 
under  medical  treatment.  He  had  never  had  gout,  but  he  was 
very  careless  as  to  his  diet,  and  his  brother  I  knew  to  be  a 
martyr  to  gout.  Under  the  use  of  alkalies  and  blue  pill  the 
angina  again  disappeared. 

7.  Venous  Throvibosis. — There  are  good  reasons  for  believing 
that  the  morbid  condition  of  blood  resulting  from  functional 
derangement  of  the  liver  not  unfrequently  leads  to  the  produc- 
tion of  venous  thrombosis.  Cases  of  this  sort  have  been  de- 
scribed as  'gouty  phlebitis'  by  Sir  James  Paget,  who  observes  : — ' 

'  The  use  of  this  name  is,  I  believe,  justified  by  the  number  of  eases 
in  which  phlebitis  is  associated  with  ordinary  gouty  inflammation  in 
the  foot  or  joints,  and  occurs,  with  little  or  no  evident  provocation,  in 
persons  of  marked  gouty  constitution,  or  with  gouty  inheritance.  In 
such  cases  the  phlebitis  may  have  no  intrinsic  characters  by  which  to 
distinguish  it ;  yet,  not  rarely,  it  has  peculiar  mai'ks,  especially  in  its 
symmetry,  apparent  metastases,  and  frequent  recurrences.  Gouty 
phlebitis  is  far  more  frequent  in  the  lower  limbs  than  in  any  other 
part ;  but  it  is  not  limited  to  the  limb  that  is,  or  has  been,  the  seat  of 
ordinary  gout.  It  affects  the  superficial  rather  than  the  deep  veins, 
and  oftener  occurs  in  patches,  affecting  (for  example)  on  one  day  a 
short  piece  of  a  saphenous  vein,  and  on  the  next  day  another  separate 
piece  of  the  same,  or  a  corresponding  piece  of  the  opposite  vein,  or  of 
a  femoral  vein.  It  shows  herein  an  evident  disposition  towards  being 
metastatic  and  symmetrical  ;  characters  Avhich,  1  may  remark,  by  the 
way,  are  strongly  in  favour  of  the  belief  that  the  essential  and  primary 
disease  is  not  a  coagulation  of  blood,  but  an  inflammation  of  portions 
of  the  venous  walls.  The  inflamed  portions  of  vein  usually  feel  hard, 
or  very  firm  ;  they  are  painful,  aching,  and  very  tender  to  the  touch  ; 
such  pain,  indeed,  often  precedes  the  clearer  signs  of  the  phlebitis,  and 

'  Treatise  on  Angina  Pectoris,  2nd  edit.  London,  1806. 
*  Op.  cit.  vol.  iv.  p.  379. 


LF.CT.  XVI.  DEEANGEMENTS    OF    CIECTJLATION.  6oi 

not  rarely  begins  suddenly.  The  integuments  and  the  affected  veins 
(where  they  are  superficial)  are  slightly  thickened  and  often  marked 
Avith  a  dusky  reddish  flush.  When  superficial  veins  alone  are  affected 
there  may  be  little  oedema  ;  but  when  venous  trunks,  as  the  femoral, 
the  whole  limb  assumes  the  characteristics  of  complete  venous  obstruc- 
tion. It  becomes  big,  clumsy,  featureless,  heavy,  and  stiff;  its  skin  is 
cool  and  may  be  pale,  but  more  often  it  has  a  partial  slightly  livid  tint, 
with  mottling  from  small  cutaneous  veins  visibly  distended.  The  limb 
thus  enlarged  feels  cedematous  all  through,  but  firm  and  tight-skinned, 
not  yielding  easily  to  pressure,  and  not  pitting  very  deeply.  By  this 
state  alone  the  disease  must  sometimes  be  recognised,  for  it  may  be 
very  marked  when  only  a  small  portion  of  vein  is  affected,  and  that 
(as  the  lower  part  of  the  popliteal)  so  deeply  seated  as  to  be  scarcely 
felt.  The  constitutional  disturbance  associated  with  this  condition  is 
that  of  slight  feverishness,  or  of  an  ordinary  gouty  attack,  more  or  less 
acute  in  different  cases.  The  effects  of  the  disease  I  have  never  had 
an  opportunity  of  examining  by  dissection,  for  in  the  only  fatal  case 
that  I  have  seen  no  autopsy  was  allowed.  So  far  as  one  may  judge  of 
them  by  after-events  during  life,  the  veins  which  may  have  been 
obstructed  become  in  some  cases  pervious  again  ;  for  in  some  cases  the 
clearing  up  of  the  oedema  and  the  restoration  of  the  healthy  condition 
of  the  limb  are  complete,  yet  the  veins  remain  apparently  very  suscep- 
tible ;  they  ache  exceedingly  during  fatigue  or  trivial  illness,  or  in 
changing  weather ;  and  I  have  known  phlebitis  excited  by  trivial 
causes  in  the  same  veins  three  or  four  times.  In  other  instances, 
however  (but  I  think  they  are  rarer  than  in  other  forms  of  phlebitis), 
the  obstruction  of  the  veins  appears  complete  and  permanent ;  and 
then,  if  they  be  trunk-veins,  the  limb  remains  permanently  enlarged, 
cumbrous,  and  heavy.  Its  superficial  veins  may  after  some  time  become 
varicose,  and  others  may  enlarge  for  collateral  blood-streams  ;  and  I 
believe  that  an  increased  growth  may  take  place  in  some  of  the  tissues, 
especially  the  muscles  of  the  limb.'  ^ 

As  in  other  forms  of  thrombosis,  so  here,  the  clot  may 
become  broken  up  and  its  fragments  be  dispersed,  and  in  this 
way  syncope,  or  even  sndden  death,  may  result  from  embolism 
of  the  pulmonary  artery.  Like  gout,  this  form  of  thrombosis 
is  often  hereditary;  but  it  is  well  to  remember  that  it  may  be 
induced  by  functional  derangement  of  the  liver  in  persons  who 
neither  inherit  gout,  nor  have  at  any  time  had  traces  of  it 
themselves. 

'  On  Gouty  and  some  other  forms  of  Phlebitis,  St.  Bartholomew's  Hosp.  Eep. 
1866,  vol.  ii.  p.  83. 


602  FUNCTIONAL    DERANGEMENTS    OP    THE    LIVEE.         lect.  xyi. 

YTI.  Derangements  of  the  Organs  of  Respiration. 

1.  Chronic  Catarrh  of  the  Fauces. — The  subjects  of  gout  or 
lithsemia  are  very  liable  tg  an  habitual  excess  of  mucous  secre- 
tion in  the  fauces  and  at  the  back  of  the  nose,  which  usually 
accumulates  during  the  night,  and  which  may  be  associated 
with  a  troublesome  cough  and  elongation  of  the  uvula.  Errors 
in  diet  usually  increase  the  amount  of  phlegm  and  may  cause 
an  extension  of  the  catarrh,  with  hoarseness  of  the  voice ;  and 
this  may  account  for  the  common  observation,  that  a  cough 
with  much  mucous  secretion  in  the  trachea  sometimes  precedes 
a  fit  of  gout.' 

2.  Chronic  Bronchitis. — The  researches  of  Trousseau,^  of  our 
colleague  Dr.  Greenhow,^  and  of  other  observers  have  clearly 
proved  that  chronic  bronchitis  has  in  many  instances  a  similar 
pathology  to  that  of  gout,  and  therefore  originates  in  func- 
tional derangement  of  the  liver.  Gout  and  bronchitis  are  very 
common  in  the  same  families ;  gout  is  disproportionately 
common  among  bronchitic  patients,  and  the  two  diseases  often 
alternate  with  one  another  in  the  same  individual,  gout  subsid- 
ing on  the  development  of  bronchitis  and  bronchitis  being- 
relieved  on  the  appearance  of  gout;  while  the  bronchitis  is 
benefited  by  the  same  remedies  as  are  useful  in  gout.  It  may 
be  added,  that  persons  who  have  never  had  gout  and  who  do  not 
come  of  a  gouty  stock,  but  who  are  the  subjects  of  lithsemia, 
are  also  very  prone  to  bronchitis. 

3.  Spasmodic  Asthma. — Although  spasmodic  asthma  consists 
essentially  in  a  morbid  proclivity  of  the  musculo-nervous  system 
of  the  bronchial  tubes  to  be  thrown  into  a  state  of  activity,  the 
stimulus  to  contraction  appears  in  some  patients  to  be  toxic,  or 
to  consist  in  the  presence  of  some  morbid  material  in  the  blood. 
'  When,'  remarks  Dr.  Todd,'*  '  the  materies  morhi  of  asthma  has 
been  generated,  its  effect  is  to  irritate  the  nervous  system,  not 
generally,  but  certain  parts  of  it,  these  parts  being  the  nerves 
concerned  in  the  function  of  respiration,  viz.  the  pneumogastric 
and  the  nerves  that  supply  the  respiratory  muscles,  either  at 
their  peripheral  extremities,  or  at  their  central  termination  in 
the  medulla  oblongata  and  spinal  cord.'  The  nature  of  this 
materies  morhi  appears  to  be  very  similar  to  that  of  gout,  and, 
like  that  of  gout,  it  appears  to  be  due  to  derangement  of  the 

'  Scudamoro,  op.  cit.  pp.  17,  377-  ^  Op.  cit,.  vol.  iv.  p.  381. 

■  On  Chronic  Bronchitis,  18G'J,  p.  55.  ■*  Mcdicul  Gazette,  December  1850, 


LECT.  XTT.    DEEANGEMENTS    OF    THE    GENITO-URINART    ORGANS.     603 

blood-changes  of  whicli  the  liver  is  the  principal  seat.  Asthma, 
like  gout,  is  an  hereditary  disease ;  it  is  common  among  persons 
springing  from  a  gouty  stock  ;  it  is  not  unfrequently  associated 
with  gout,  gall-stones,  or  other  hepatic  derangements  in  the 
same  individual ;  and  attacks  of  asthma  have  been  known  to 
alternate  periodically  with  attacks  of  gout.  Moreover,  an 
asthmatic  paroxysm,  like  an  attack  of  gout,  of  vertigo,  or  of 
sleeplessness,  is  often  excited  by  a  fit  of  indigestion  and  by  the 
use  of  particular  articles  of  diet.  Our  late  colleague  Dr.  Hyde 
Salter,  who  did  so  much  to  throw  L!ght  upon  the  pathology  of 
asthma,  was  of  opinion  that  the  asthmatic  paroxysm  in  the 
cases  now  referred  to  was  produced  by  '  the  actual  presence  in 
the  vessels  of  the  lungs  of  the  materials  taken  up  from  the  sto- 
mach and  intestines  ; '  ^  but  it  seems  to  me  that  the  materies 
morhi  is  far  more  likely  to  be  a  product  of  hepatic  derangement 
consequent  on  the  unwholesome  ingesta,  as  in  the  analogous 
attacks  of  gout,  vertigo,  etc. 

VIII.  Derangements  of  the  Genito-Urmary  Organs. 

The  remarks  which  I  have  already  made  render  it  unneces- 
sary for  me  to  insist  further  on  the  tendency  of  functional  de- 
rangement 01  the  liver  to  produce  urinary  symptoms.  I  will 
merely  repeat  that  hepatic  disorder  is  a  common  cause  of — 

1.  Deposits  of  Lithic  Acid  and  Lithatesin  the  Urine  (p.  565). 

2.  Renal  Calculi  (p.   568). 

3.  Diseases  of  the  Kidneys  and  Albuminuria  {^.  b*l 2). 

4.  Cystitis  is  occasionally  excited  by  the  lithic  acid  diathesis. 
It  is  often  preceded  by  an  excess  of  lithic  acid  in  the  urine,  by 
a  disappearance  of  an  eczematous  eruption,  or  by  an  attack  of 
dyspepsia.  The  attack  is  often  sudden  in  its  invasion  and 
rapid  in  its  subsidence. 

5.  Urethritis. — Not  only  may  lithsemia  modify  or  protract 
an  ordinary  gonorrhoea,  but  it  is  sometimes  the  primary  cause  of 
acute  urethritis.  On  this  point  1  cannot  do  better  than  quote 
the  words  of  Sir  James  Paget  :^'  Acute  inflammation  of  the 
mucous  membrane  of  the  urethra,  attended  with  the  usual  signs 
of  gonorrhoea — purulent  discharge,  scalding,  frequent  micturi- 
tion, and  painful  erections — occurred  as  a  direct  consequence  of 
gout.  These  cases  were  certain  ;  they  occurred  where  there  had 
been  no  infection  and  they  were  not  themselves  infectious.'  ^ 

»  On  Asthma,  1860,  pp.  46,  117.  "^  Brit.  Med.  Journ.  1875,  i.  701. 


604  FUNCTIONAL   DERANGEMENTS    OP    THE    LIVER.        lect.  xvi. 

6.  Chorclee. — Persistent,  and  sometimes  painful,  erections 
of  the  penis  during  sleep  occasionally  result  from  litlisemia, 
especially  in  elderly  persons.  Even  in  persons  of  middle  age  I 
have  known  them  to  be  a  cause  of  constant  restlessness,  which 
is  often  relieved  by  blue-pill,  alkalies,  and  bromide  of  potas- 
sium. 

7.  Orchitis,  sometimes  acute  and  sometimes  chronic,  is 
another  result  of  lithsemia  or  gout.  The  chronic  form  is  often 
attended  by  hydrocele  and  sometimes  leads  to  the  formation 
of  indurated  masses  in  the  testicle  or  epididymis,  which  are 
mistaken  for  tubercle  or  cancer,  but  which  disappear  under 
time  and  treatment. 

IX.  Abnormal  Conditions  of  the  SJcin. 

There  is  good  evidence  that  many  disorders  of  the  skin 
originate  in  derangements  of  the  processes  of  oxydation  or 
disintegration  which  go  on  in  the  liver. 

1.  Almost  all  observers  are  agreed  that  Eczema,  Lepra, 
Psoriasis,  and  Lichen  may  arise  from  lithsemia.  Many  years 
ago  the  late  Sir  Henry  Holland  remarked  that  he  had  '  so 
often  seen  psoriasis  prevailing  in  gouty  families — sometimes 
alternating  with  acute  attacks  of  that  disease,  sometimes  sus- 
pended by  them,  sometimes  seeming  to  prevent  them  in  in- 
dividuals thus  disposed — that  it  is  difficult  not  to  assign  the 
same  morbid  cause  to  these  results.'  ^  Our  late  distinguished 
President,  Sir  Thomas  Watson,  in  his  '  Practice  of  Medicine,' 
speaks  of  lepra  and  psoriasis  as  blood-diseases  depending  upon 
some  poisons  bred  within  the  body.^  Dr.  Garrod  also  bears 
testimony  to  the  frequent  connection  of  eczema  and  psoriasis 
with  gout ;  while  Sir  James  Paget  has  pointed  out  that  those 
patients  in  whom  the  local  application  of  arnica  to  the  skin  is 
followed  by  erysipelas,  with  great  pain,  vesication,  and  desqua- 
mation, are  always  of  gouty  constitution.^  My  own  experience 
fully  bears  out  the  correctness  of  these  observations  ;  but  in  many 
cases  these  cutaneous  diseases  appear  to  arise  from  the  func- 
tional derangement  of  the  liver  which  precedes  or  attends  gout, 
and  yet  neither  the  patient  nor  any  member  of  his  family  has 
ever  suffered  from  this  disease.     On  this  point  Dr.  Tilbury  Fox, 

'  Medical  Notes  and  Keflections. 

*  Lectures  on  the  Principles  and  Practice  of  Medicine,  5tli  edit.  1871,  vol,  ii.  p. 
1023.  «  Brit.  Med.  Journ.  1875,  i.  633. 


I.ECT.  XVI.  ABNORMAL    CONDITIONS    OP    THE    SKIN.  605 

in  his  recent  work  on  cutaneous  diseases,  makes  the  following 
pertinent  remarks  :  *  All  disorders  which  are  connected  with 
retention  of  excreta  in  the  system  and  their  circulation  through- 
out the  blood-current  may  furnish  the  exciting  cause  of  eczema. 
This  is  a  clinical  fact  of  very  great  importance.  Given  the 
tendency  to  eczema,  then  the  transmission  of  uric  acid  through 
the  capillaries  of  the  skin  will  so  far  derange  as  to  aggravate 
certainly,  and  now  and  again  excite,  an  eczematous  eruption. 
This  is  what  is  meant  by  gouty  eczema ;  and,  by  securing  the 
absence  of  uric  acid  from  the  circulation,  the  eczema  will  often 
disappear  and  always  be  more  amenable  to  treatment.  .  .  . 
Such  cases  as  I  now  refer  to  sometimes  exist  off  and  on  for 
years  and  are  saturated  with  arsenic  and  mercurials,  but  are 
only  relieved  by  recognising  the  complicating  item  of  the  free 
production  and  circulation  of  uric  acid,  and  by  instituting  a 
regime  calculated  to  arrest  the  continuance  of  those  conditions.'  ^ 
Dr.  Fox  also  calls  attention  to  the  fact  that  children  with 
eczema  have  often  white  stools.^ 

Anatomically  there  is  nothing  to  distinguish  these  cutaneous 
eruptions  from  those  due  to  other  constitutional  states  ;  but  it 
will  often  be  observed  that  their  invasion  is  sudden  and  attended 
by  dyspeptic  symptoms,  and  that  they  follow  the  ingestion  of 
food  which  has  been  known  to  disagree. 

2.  Urticaria  I  have  not  unfrequently  met  with  in  connection 
with  jaundice  and  other  derangements  of  the  liver.  The  late 
Dr.  Graves  observed  eight  or  nine  instances  of  persons  suffering 
from  acute  rheumatism  who  became  suddenly  jaundiced  from 
the  supervention  of  hepatitis  (congestion  of  liver?),  and  in 
whom  the  jaundice  was  followed  by  urticaria.^  Among  the 
causes  of  urticaria.  Dr.  Tilbury  Fox  mentions  '  the  circulation 
of  acrid  or  effete  products,  for  example,  uric  acid,  bile,  etc., 
which,  coming  to  the  surface,  become  oxydised  and  more 
active.' ''  He  also  mentions  that  '  asthma  has  been  observed 
to  be  associated  with  urticaria  in  a  peculiar  manner '  ^ — an 
association  which  is  readily  explained  by  the  foregoing  remarks. 
Scudamore  refers  to  violent  urticaria  as  existing  for  two  days 
before  a  gouty  parox3'sm ;  ^  and  I  have  myself  known  patients 
in  whom  champagne  or  certain  articles  of  diet  have  almost 
invariably   produced   either   gout   or   urticaria.      Recently,    I 

'  Skin  Diseases,  3rd  edit.  1873,  p.  17o.  ^  lb.  p.  11. 

'  Clinical  Lectures  on  the  Practice  of  Medicine,  2nd  edit.  vol.  i.  p.  446. 
*  Op.  cit.  p.  120.  5  iij  p,  121.  8  Op.  cit.  p.  103. 


6o6  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.        lbct.  xti. 

have  had  under  my  care  a  boy,  aged  9,  with  urticaria  tuherosa 
andpftrpwa  urticans^  complicated  with  haemorrhages  from  the 
bowels,  kidneys,  and  urinary  passages,  and  wiih  the  discharge 
of  much  lithic  acid  in  the  urine,  which  there  was  good  reason 
for  suspecting  to  be  due  in  the  first  instance  to  functional 
derangement  of  the  liver. 

3.  Boils  and  Carbuncles  are  occasionally  observed  in  connec- 
tion with  jaundice  and  are  also  excited  by  the  presence  in  the 
blood  of  urea  and  other  effete  products.  In  the  connection 
also  between  phlegmonous  or  carbuncular  inflammation  and 
diabetes,  it  is  possible  again  to  trace  the  influence  of  a  dis- 
ordered liver  in  the  production  of  shin-diseases. 

4.  Pigment-spots  of  various  sorts  on  the  face,  hands,  and 
other  parts  of  the  body  are  not  uncommon  in  functional  de- 
rangements of  the  liver.  They  are  sometimes  designated  '  liver- 
spots  '  by  non-professional  persons,  who,  perhaps,  attach  too 
much  importance  to  them  as  indicative  of  hepatic  derangement. 
They  may,  as  Dr.  Laycock  observes,  be  induced  by  imperfect 
oxydation,  or  excessive  production  of  carbon,  in  derangements 
of  the  liver,^  but  they  may  also  arise  in  other  ways. 

5.  Xanthelasma  or  Vitiligoidea,  which  consists  in  a  fatty 
degeneration  of  the  subcutaneous  or  submucous  tissue  analo- 
gous to  atheroma,  is  a  remarkable  affection  of  the  skin,  often 
associated  with  liver-derangement.  (See  Lecture  VII.,  p.  247^ 
and  Lecture  IX.  p.  318). 

6.  Pruritus  is  a  troublesome  symptom  which  often  results 
fi'om  hepatic  derangement.  It  is  known  to  be  a  frequent 
accompaniment  of  jaundice ;  but  it  is  not  due  to  the  presence 
of  bile  in  the  blood,  for  in  many  cases  of  jaundice  it  is  absent, 
and  I  have  repeatedly  known  it  precede  the  appearance  of 
jaundice  by  several  weeks,  or  cease  while  the  jaundice  persisted. 
Moreover,  I  have  frequently  known  itchiness  of  the  skin  a 
source  of  extreme  distress  to  patients  with  hepatic  derange- 
ment unaccompanied  by  jaundice.  It  may  attack  various 
parts  of  the  body  in  succession,  or  it  may  be  universal.  It  is 
unattended  by  any  eruption.  It  is  always  worse  in  heated  rooms 
and  after  stimulating  food,  and  it  is  greatly  aggravated  by 
scratching ;  not  unfrequently  it  appears  with  the  advent  of 
winter.  This  symptom  is  not  uncommon  in  gout}^  people''^  and 
in  subjects  of  the  lithic  acid  diathesis,  and  it  is  often  removed 
by  attention  to  diet  and  a  few  doses  of  blue  pill  and  alkalies. 

•  Fox,  op.  cit.  p.  401.  *  Scudiimore,  op.  cit.  p.  103. 


I.ECT.   XYr. 


CAUSES-  607 


As  Dr.  Ben^e  Jones  lias  observed,  '  itching,  nettle-rash,  eczema, 
and  herpes  are  the  outbursts  of  an  over- acid  state.'  ^ 

C.      CAUSES    OF    FUNCTIONAL    DERANGEMENTS    OP   THE    LIVER. 

The  remarks  which  I  shall  make  under  this  head  will  be 
restricted  to  abnormal  disintegration  in  the  liver.  The  causes 
of  diabetes  and  of  certain  other  functional  derangements  of  the 
liver  have  been  already  referred  to.  The  disorder  of  the  liver 
which  induces  lithsemia  may  be  primary,  or  secondary  to  other 
morbid  states  of  the  body.  It  is  with  the  former  that  we  are  now 
chiefly  concerned  ;  but  the  main  causes  of  secondary  derange- 
ment of  the  liver  may  be  briefly  referred  to.  They  are  as 
follows  : — 

1.  All  structural  diseases  of  the  liver  derange  more  or  less 
the  functions  of  the  organ.  These  derangements  are  usually 
judged  of  solely  by  the  characters  of  the  alvine  evacuations,  and 
the  far  more  important  functions  of  sanguification  and  depura- 
tion of  the  blood  performed  by  the  liver  are  lost  sight  of.  But 
it  is  well  to  remember  that  in  structural  diseases  of  the  liver 
these  functions  may  be  seriously  deranged,  without  any  obvious 
change  in  the  characters  of  the  stools.  In  all  structural  diseases 
of  the  liver  unattended  by  fever  and  involving  a  considerable 
destruction  of  the  glandular  tissue,  there  is  a  tendency  to  a 
diminished  excretion  of  urea  and  an  increase  of  lithates  in  the 
urine,  and  before  long  the  patient  becomes  anaemic.  At  last, 
symptoms  of  blood-poisoning  may  supervene,  although  there 
may  be  no  jaundice  and  plenty  of  bile  in  the  motions.  These 
results  are  well  seen  in  acute  atrophy  of  the  liver  ;  but  are 
also  notable,  though  in  a  less  degree,  in  abscess,  cirrhosis 
cancer,  etc. 

2.  Disorders  of  the  Gastric  and  Intestinal  Digestion  often  lead 
to  secondary  derangement  of  the  liver.  For  example,  the  liver 
may  become  deranged  as  the  result  of  gastric  dyspepsia,  or  of 
protracted  constipation  from  atony  of  the  bowels  or  from  de- 
ficient intestinal  secretion ;  and  sometimes  it  may  be  difficult 
to  say  whether  the  hepatic  derangement  is  primary  or  secon- 
dary. 

3.  Diseases  of  the  Heart  and  Lungs,  by  obstructing  the  circu- 
lation and  impeding  oxydation,  are  a  common  cause  of  func- 
tional and  ultimately  indeed  of  structural  disease  of  the  liver. 

1  Lectures  on  Pathology  and  Therapeutics,  1867,  p.  84. 


6o8  FUNCTIONAL    DEEANGEMENTS    OF    THE    LIVER.        lect.  XT^ 

It  is  unnecessary  for  me  liere  to  insist  on  the  frequency  witli 
which  the  symptoms  of  valvular  disease  of  the  heart  are  agg-ra- 
vated  by  those  of  functional  derangement  of  the  liver,  and  on 
the  necessity  of  attending  to  these  in  the  treatment  of  the 
j)rimary  disease. 

4.  Pyrexia. — In  all  diseases  attended  by  pyrexia,  whether 
arising  from  some  general  cause,  such  as  a.  specific  poison,  or 
from  a  local  inflammation,  there  is  more  or  less  functional 
derangement  of  the  liver.  The  liver,  indeed,  plays  a  prominent 
-paxt  in  the  pathology  of  the  febrile  process.  It  is  one  of  the 
few  parts  of  the  body  which  do  not  waste  during  the  fever. 
On  the  contrary,  it  becomes  enlarged  and  congested,  while  its 
gland-cells  are  swollen  out  with  minute  albuminous  granules ; 
and  it  is  well  known  that  these  changes  are  attended  by  an  in- 
creased disintegration  of  albuminous  matter  and  an  increased 
production  of  urea  and  less  oxydised  products.  On  the  cessa- 
tion of  the  febrile  process  the  liver  resumes  its  normal  functions ; 
but  now  and  then  it  happens  that  after  a  severe  attack  of  fever 
these  functions  are  permanently  impaired.  I  have  repeatedly 
known  a  permanent  tendency  to  hepatic  derangement  induced 
by  a  severe  attack  of  typhus,  enteric,  malarious,  or  scarlet 
fever,  in  persons  who  had  exhibited  no  such  tendency  pre- 
viously. 

Functional  derangements  of  the  liver,  when  primary,  may  be 
due  to  a  variety  of  causes.     Of  these  the  principal  are — 

1.  Errors  in  Diet. — There  can  be  no  doubt  that  the  present 
system  of  living  and  especially  the  consumption  of  even  what 
are  regarded  as  average  quantities  of  rich  food  and  stimulating 
drinks  contribute  largely  to  derange  the  liver.  It  will  be  gene- 
rally admitted,  nor  would  it  be  difficult  to  prove,  that  most 
persons  are  in  the  habit  of  eating  a  quantity  of  food  far  greater 
than  suffices  to  maintain  the  nutrition  of  the  body.  Much  of 
this  excess  is  fortunately  never  assimilated  and  is  got  rid  of  in 
the  fseces :  but  very  often  much  more  is  taken  into  the  blood 
than  can  be  converted  into  tissue  or  pass  through  the  ordinary 
processes  of  oxydation  preparatory  to  elimination.  The  result 
is  that  the  excess  of  food  is  thrown  out  in  an  imperfectly  oxy- 
dised form  by  the  kidneys,  lungs,  etc.,  or  accumulates  in  the 
system ;  while  more  work  is  thrown  upon  the  liver  than  it  can 
readily  perform,  and  functional  derangement  of  the  organ 
ultimately  ensues.  With  regard  to  individual  elements  of  food, 
speaking  generally,  it  may  be  said  that  the  liver  is  most  apt 


LECT.  XVI.  CAUSES.  609 

be  deranged  by  saccharine  and  fiittj  substances.  Tbe  derange- 
ment of  the  liver  which  leads  to  lithsemia  or  gout  is  more  likely 
to  be  induced  by  even  small  quantities  of  these  substances  than 
by  a  moderate  excess  of  purely  nitrogenous  food,  such  as  meat. 
Cooked  articles  of  diet  containing  a  large  proportion  of  both 
sugar  and  fatty  matter  are  in  many  persons  certain  to  derange 
the  liver.  The  excess  of  carbon  in  these  substances  must 
either  be  deposited  as  fat  or  must  take  away  the  oxygen,  so  as 
to  leave  little  free  to  act  on  the  nitrogenous  matter  passing  out 
from  the  tissues  or  derived  from  the  food ;  and  hence,  as  Dr. 
Bence  Jones  has  observed  in  speaking  of  gout,  '  with  carbona- 
ceous diet  in  excess,  the  whole  of  the  uric  acid  from  the  tissues 
might  pass  off  through  the  blood  unoxydised.'  ^  There  are 
also  constitutional  peculiarities  with  regard  to  many  articles 
of  food,  which  always  derange  the  liver  in  certain  individuals, 
though  they  are  comparatively  harmless  in  others. 

But  of  all  ingesta  the  various  alcoholic  drinks  are  most  apt 
to  derange  the  liver.  They  do  so  in  two  ways.  a.  They  may 
cause  persistent  congestion  of  the  liver.  Even  small  quantities 
of  alcohol  in  healthy  persons  produce  a  temporary  hepatic  con- 
gestion :  but  if  alcohol  be  taken  in  excess,  or  too  frequently,  the 
congestion  of  the  liver  becomes  permanent  and  the  functions  of 
the  organ  are  deranged.  Like  results  may  ensae  from  com- 
paratively small  quantities  in  certain  persons,  who  may  be  said 
to  have  a  constitutional  intolerance  of  alcohol.  Of  course,  if 
the  congestion  be  long  maintained,  structural  disease  may 
follow,  h.  But  wines  and  other  alcoholic  drinks  often  cause 
derangement  of  the  liver,  which  a  corresponding  quantity  of 
pure  alcohol  would  not  produce,  and  which,  in  fact,  cannot  be 
accounted  for  by  any  one  ingredient  of  the  offending  liquid — 
neither  by  the  free  acid,  the  ether,  the  salts,  gum,  sugar,  nor 
extractive  matter.  This  general  rule,  however,  I  believe  holds 
good,  that  the  injurious  effect  of  alcoholic  beverages  upon  the 
liver  increases  in  a  direct  ratio  with  the  amount  of  sugar  plus 
alcohol  which  they  contain.  It  would  seem,  indeed,  that  a 
mixture  of  alcohol  and  sugar  produces  injurious  results  which 
would  not  be  caused  by  the  admixture  of  a  much  larger  quan- 
tity of  sugar,  or  of  alcohol  alone,  with  the  food.  In  accordance 
with  this  view,  the  alcoholic  drinks  which  are  found  from  ex- 
perience to  be  most  apt  to  disagree  with  the  liver  are  malt 
liquors  of  all  sorts,  but  especially  porter  and  the  stronger  forms 

'  Op.  cit.  p.  14:2. 
E,  E 


6lO  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.         lect.  xvi. 

of  mild  ale,  port  wine,  madeira,  tokaj,  malaga,  sweet  cliam.pagiie, 
dark  sTierries,  liquears,  and  brandy;  whilst  those  which  are 
least  likely  to  derange  the  functions  of  the  organs  are  claret, 
hock,  moselle,  dry  sherry,  and  gin  or  whisky  largely  diluted. 

Derangement  of  the  liver  from,  excessive  eating  or  from 
other  errors  in  diet  usually  first  shows  itself  in  middle  life — 
from  thirty-five  to  forty-five.  Young  people,  who  take  much 
exercise  and  whose  bodies  are  still  undergoing  development, 
require  more  food  and  can  with  impunity  eat  more  than  they 
require.  But  by  the  age  of  forty  the  body  is  fully  developed 
and  most  persons  take  less  exercise  than  before,  while  at  the 
same  time  they  often  indulge  more  freely  at  table.  At  any  age 
errors  in  diet  will  be  all  the  more  likely  to  tell  upon  the  liver,  if 
there  be  any  constitutional  weakness  in  the  functional  power  of 
the  organ. 

2.  A  Deficient  Sujp'ply  of  Oxygen. — Tnsuflfi.cient  muscular 
exercise  in  the  open  air  may  derange  the  functions  of  the  liver. 
It  is  well  known  that  sedentary  habits  and  confinement  in 
badly  ventilated  rooms  tend  to  induce  derangements  of  the 
liver.  It  is  also  a  common  observation  that  persons  who  have 
eaten  and  drunk  too  freely  have  not  suffered  from  their  livers 
so  long  as  they  have  led  an  active  life  in  the  open  air  ;  but  that, 
as  soon  as  from  change  of  occupation,  or  other  causes,  they  take 
to  sedentary  habits,  without  any  corresponding  change  in  diet, 
derangement  of  the  liver  ensues.  Again,  every  sportsman  who 
has  suffered  from  hepatic  derangement  knows  the  effect  of  a 
single  day's  hunting  or  shooting  in  clearing  his  complexion  and 
relieving  his  symptoms.  A  want  of  regular  exercise  in  the 
open  air  leads  to  derangement  of  the  liver  in  two  ways ;  viz.,  a, 
by  diminishing  the  elimination  of  free  acid  and  causing  a  defi- 
cient supply  of  oxygen  to  the  system,  as  the  result  of  which  the 
oxydising  processes  which  go  on  in  the  liver  and  elsewhere  are 
imperfectly  performed,  and  there  is  a  tendency  to  the  accumu- 
lation in  the  system  of  fat  and  of  the  imperfectly  oxydised  pro- 
ducts of  disintegrated  albumen.  Oxygen  is,  so  to  speak,  the 
antidote  necessary  for  the  destruction  of  a  materies  morhi  (lithic 
acid,  etc.)  produced  by  imperfectly  oxydised  albumen,  h.  By 
retarding  the  circulation  of  blood  through  the  liver.  Since  the 
time  of  Haller,^  physiologists  have  recognised  the  influence  of 
the  respiratory  movements  in  promoting  the  circulation  of  blood 

'  '  Vires  qiu«  sanguinis  per  lic]i;ir  moduli  accelerant.' — ITallcr's  T'liysiologia,  17G4, 
torn.  vi.  p.  GOl. 


LECT.  XVI.  CAUSES.  6ll 

through,  the  liver;  but,  upwards  of  thirty  years  ago,  Mr. 
Alexander  Shaw,  in  a  paper  which  has  attracted  too  little 
notice,'  showed  more  clearly  than  ever  before  that  the  circula- 
tion of  blood  through  the  liver  was  greatly  influenced  by  the 
alternate  expansion  and  contraction  of  the  thorax  during  re- 
spiration. Mr.  Shaw  called  attention  to  the  fact  that  the  portal 
vein,  without  any  provision  for  increasing  its  power,  or  any 
assistance  beyond  that  vis  a  tergo  which  belongs  to  the  veins 
generally,  and  being  even  destitute  of  valves  to  protect  it  from 
regurgitation  of  blood  like  the  veins  in  other  parts  of  the  body, 
has  to  perform  the  duty  usually  fulfilled  by  an  artery,  which, 
besides  receiving  an  impulse  from  the  heart,  is  aided  in  distri- 
buting its  blood  by  the  contractility  and  elasticity  of  its  coats. 
He  suggested  that  this  weak  power  by  which  the  portal  vein 
propelled  its  blood  was  compensated  for  by  a  suction-force  com- 
municated to  the  current  of  blood  by  the  actions  of  respiration : 
the  deeper  the  inspiration,  the  greater  the  force  with  which  the 
blood  rushes  by  the  large  veins  to  the  right  auricle.  These 
reasonings  have  been  confirmed  by  certain  experiments  of  M. 
Bernard,  who  has  found  that  when  an  incision  is  made  into  a 
lobe  of  the  liver  in  a  living  animal  the  blood  may  be  seen  to  jet 
from  the  mouth  of  the  hepatic  veins  during  the  movements  of 
expiration,  but  to  return  sucking  in  air  with  it  at  each  deep  in- 
spiration, so  that  the  animal  soon  dies  from  the  passage  of  air 
into  the  heart.^  In  persons,  then,  who  lead  a  sedentary  life  this 
auxiliary  force  for  promoting  the  circulation  of  blood  through 
the  liver  is  diminished,  blood  stagnates  in  the  gland,  and  the 
functions  of  the  organ  are  deranged,  these  results  being  all  the 
more  likely  to  arise  if  the  liver  be  at  the  same  time  overstimu- 
lated  by  errors  in  diet. 

3.  A  high  tem-perahire  favours  certain  functional  derange- 
ments of  the  liver,  and  particularly  those  relating  to  sanguifica- 
tion and  disintegration  of  albumen.  Functional  derangements, 
as  well  as  congestion  and  inflammation  of  the  liver,  are  more 
apt  to  occur  in  tropical  than  in  temperate  climates,  and  in  our 
own  country  the  liver  more  often  becomes  disordered  in  summer 
and  autumn  than  in  winter.  The  diet  which  is  suitable  in  a 
cold  or  temperate  climate  produces  in  the  tropics  hepatic 
derangement.  These  results  of  a  heated  atmosphere  are,  no 
doubt,  due  in  part  to  the  rarefaction  of  the  air  and  acorrespoud- 

1  Medical  Gazette,  July  15  and  September  30,  1842. 

2  London  Medical  Eeeord,  October  15,  1873,  p.  647. 

B    B  2 


6l2  FUNCTIONAL    DERANGEMENTS    OP    THE    LIVER.         lbct.  xvi. 

ing  diminution  in  the  supply  of  oxygen  to  the  system ;  the 
hotter  the  air,  the  less  will  be  the  amount  of  oxygen  in  a  given 
volume  inhaled  by  the  lungs.  But  this  is,  perhaps,  not  the 
sole,  if  the  chief,  explanation.  Experiment  has  shown  that  one 
of  the  effects  of  a  high  temperature  upon  the  lower  animals  is 
to  produce  a  degeneiation  of  the  parenchyma  of  the  liver,  its 
secreting  cells  becoming  filled  with  minute  granules  and  pre- 
senting aj)pearances  similar  to  those  found  after  death  from 
febrile  diseases.'  It  is  possible,  then,  that  some  of  the  func- 
tional derangements  of  the  liver  from  which  persons  suffer  in 
tropical  climates  may  be  owing  to  similar  degenerations,  not 
necessarily  permanent,  of  the  secreting  cells. 

4.  Nervous  Influences. — Many  facts  show  the  great  influence 
of  the  nervous  system  upon  the  secreting  organs.     Sudden  fear, 
or  other  severe  mental  emotion,  has  been  known  to  arrest  the 
secretion  of  milk  and  saliva,  and  we  have   already  seen  how 
injuries  and  diseases  of  nerve-tissue  may  produce  diabetes  by 
deranging  the  gly oogenous  function  of  the  liver.     But  many 
other   ailments    of  the   liver  besides  diabetes  have  a  nervous 
origin.     Prolonged  mental  anxiety,  worry,  and  incessant  mental 
exertion  not  only  interfere  with  the  proper  secretion  of  bile, 
but   too    often  derange   the   processes    of   sanguification    and 
blood-change,  in  Avhich  the  liver  is  so  deeply  concerned,  and 
induce  lithsemia  with  many  of  the  symptoms  already  described. 
Gravel  and  gout  are  acknowledged  to  be  the  frequent  lot  of 
those  who  live    more  by  nerve-  than  b}^  muscle-work.     Such 
results  are  all  the  more  likely  to  ensue  if  the  diet  has  been 
such  as  favours  hepatic  derangement — if,  for  example,  to  drown 
grief,  the  patient  has  indulged  in  stimulants — and  the  habits 
have  been  sedentary.     There  is  also  good  evidence  that  nervous 
agencies  may  not  only  cause  functional  derangement,  but  even 
structural  disease,  of  the  liver.     Acute  atrophy,  in  which  the 
secreting    cells    are   rapidly   disintegrated   and   the   functions 
of  the  organ  arrested,  appears  in  many  instances  to  have  a 
purely  nervous  origin ;    very  often  the  first  symptoms  of  the 
disease  have  occurred  immediately  after  a  severe  fright,  or  an 
outburst  of  passion,  in  a  person  previously  healtliy.     An  im- 
pression made  upon  the  bi-ain  appears  to  be  reflected  to  the 
liver  and  to  derange  its  nutrition.     Many  observations  have 
satisfied  me  that  the  extrusion  of  gall-stones  from  the  gall- 
bkidder,  ns  well  as  their  formation,  may  be  traced  to  norvous 
'  See  Pathological  Triinsactions,  1873,  toI.  xxiv.  p.  26C. 


i,KCT.  XVI.  CAUSES.  613 

agency.  Dr.  Budd  lias  also  observed  that  mental  anxiety  or 
trouble  has  '  great  influence  in  the  production  of  gall-stones  ; ' ' 
and  I  have  repeatedly  known  attacks  of  biliary  colic  from  gall- 
stones excited  by  some  sudden  emotion.  Lastly,  even  cancer 
of  the  liver  appears  sometimes  to  result  from  the  functional 
derangement  induced  in  the  first  instance  by  mental  trouble. 
I  have  been  surpi-ised  at  the  frequency  with  which  patients 
suffering  from  primary  cancer  of  the  liver  have  traced  the 
commencement  of  their  ill-health  to  indigestion  following 
protracted  grief  or  anxiety.  The  cases  have  been  far  too 
numerous  to  be  accounted  for  on  the  supposition  that  the 
mental  distress  and  the  cancer  have  been  mere  coincidences. 
A  similar  observation  has,  I  believe,  been  made  by  Sir  Robert 
Christison  and  by  other  eminent  authorities. 

5.  Constitutional  Peculiarities.- — In  considering  the  causes  of 
functional  derang'ement  of  the  liver  it  must  not  be  forgotten 
that  there  are  constitutional  peculiarities — inherited  or  acquired 
— in  virtue  of  which  the  liver  is  deranged  from  causes  which 
under  ordinary  circumstances  would  be  harmless.  Most  persons, 
as  Dr.  Budd  observes,  have  more  liver,  just  as  they  have  more 
lung,  than  is  absolutely  necessary.^  A  portion  of  their  liver 
may  be  destroyed  hy  disease,  or  become  less  active,  without  any 
derangement  of  the  general  health.  In  others,  the  liver  seems 
only  just  capable  of  performing  its  functions  under  the  most 
favourable  conditions,  and  it  at  once  breaks  down  under  adverse 
circumstances  of  diet,  habits,  or  climate.  This  innate  weakness 
of  the  liver  is  often  inherited.  The  person  is  born  with  a 
tendenc}''  to  biliary  derangements.  Gout  and  diabetes,  which 
we  have  found  to  originate  in  hepatic  derangement,  are  here- 
ditary diseases  ;  and  the  liver  is  always  very  readily  disordered 
in  persons  who  inherit  a  tendency  to  gout.  This  constitutional 
tendency  to  hepatic  derangement  is  too  often  lost  sight  of  by 
patients,  and  perhaps  sometimes  by  their  medical  advisers. 
The  habitual  use  of  alcohol  is  often  recommended  for  various 
ailments  by  the  medical  attendant,  without  due  regard  to  the 
tendency  of  the  individual  to  hepatic  derangement,  and  thus 
serious  consequences  may  ultimately  arise  from  alcohol  taken 
with  a  medicinal  object.  Again,  a  patient  often  argues  that 
his  liver-troubles  cannot  be  due  to  what  he  eats  or  drinks, 
because  he  is  most  careful  as  compared  with  friends  who  indulge 
largely  and  suffer  nothing,  forgetting  the  adage:  'One  man's 

'  Diseases  of  the  Liver,  3rd  edit.  1857.  p.  369.  -'  Op.  cit.  p.  55. 


6l4  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.        lect.  xti. 

food  is  another  man's  poison.'  One  man,  for  instance,  may 
drink  a  bottle  of  wine  and  be  none  the  worse,  whereas  another 
has  his  liver  deranged  by  a  single  glass. 

6.  Poisons  of  various  sorts  may  derange  the  liver,  the  per- 
sistence of  the  derangement  depending  upon  the  length  of  ex- 
posure to  the  cause.  One  of  the  first  effects  of  the  poisons  of 
the  various  specific  fevers  is  ujDon  the  liver.  Again,  from 
protracted  exposure  to  malaria,  the  liver  often  becomes  deranged, 
ansemia  and  lithsemia  being  the  results.  While  some  cases  of 
acute  atrophy  of  the  liver  have  a  nervous  origin,  there  is  good 
evidence  that  others  are  caused  by  a  XDoison  taken  into  the 
body  from  without,  or  sometimes,  as  suggested  by  Dr.  Budd, 
'  engendered  in  the  body  by  faulty  digestion  and  assimilation.' 
Phosphorus  also,  in  sufficient  doses,  is  known  to  derange  the 
functions  of  the  liver ;  and  one  result  of  phosphorus-poisoning 
is  the  production  of  symptoms  and  structural  changes  in  the 
liver  closely  resembling  those  of  acute  atrophy.^  Various  sub- 
stances also  taken  as  food,  or  by  mistake  along  with  food,  may 
induce  functional  disturbance  of  the  liver,  the  poisonous  effect 
being  often  determined  by  some  constitutional  peculiarity  of 
the  individual. 

These  causes  of  functional  derangement  of  the  liver  will, 
of  course,  act  more  injuriously  if  the  functions  of  the  liver  be 
already  disordered  by  structural  disease,  by  disease  of  the  heart 
or  lungs,  or  by  derangements  of  the  stomach  and  bowels. 

D. — TREATMENT    OF    FUNCTIONAL    DERANGEMENTS    OF    THE 

LIVER. 

The  time  at  my  disposal  onl}^  permits  me  to  give  a  brief 
sketch  of  the  general  principles  on  which  functional  derange- 
ments of  the  liver  ought  to  be  treated  ;  and  my  remarks  will  be 
for  the  most  part  restricted  to  the  derangements  resulting  from 
abnormal  disintegration  and  abnormal  elimination. 

1 .  Diet. — In  functional  derangements  of  the  liver,  much 
more  permanent  benefit  is  to  be  expected  from  careful  regula- 
tion of  the  ingesta  than  from  physic.  It  must  not  be  forgotten 
that  what  may  ultimately  destroy  the  body  too  often  enters  by 

'  Lead  is  known  to  cause  an  accumulation  of  lithic  acid  in  the  system,  but  appa- 
rently by  impeding  its  excretion  by  the  kidneys,  rather  than  by  increasing  its  forma- 
tion in  the  liver.  (See  Garrod,  op.  cit.  p.  292.)  Bence  Jones,  on  the  other  hand,  main- 
tains that  the  accumulation  of  lithatcs  in  the  system  produced  by  lead  is  to  be 
ascribed  to  diminished  oxydation.    (Lectures  on  Pathology  and  Therapeutics,  p.  289. 


iKCT.    XVI. 


TREATMENT.  615 


the  same  portal  as  tliat  vvhicli  is  intended  to  nourisli  and 
maintain  it,  and  that  for  the  maintenance  of  health  it  is  neces- 
sary for  most  persons  to  put  a  curb  upon  their  aj)petites.  To 
use  the  words  of  the  late  Sir  Benjamin  Brodie,  'We  are  all 
anxious  to  obtain  rank,  reputation,  and  wealth;  but  that  for 
which  we  have  most  reason  to  be  anxious,  not  only  for  our  own 
sake,  but  also  for  that  of  others,  is  such  a  state  of  our  bodily 
functions  as  will  enable  us  to  make  use  of  our  higher  faculties, 

and  promote  in  us  happy  and  contented  feelings The 

agricultural  labourer  who  has  enough  of  wholesome  food  and 
warm  clothing  for  himself  and   his  family,  and  who  has  the 
advantage  of  living  in  the  open  air,  has  more  actual  enjoyment 
of  life  than  the  inheritor  of  wealth  living  in  a  splendid  mansion, 
who  has  too  much  of  lithic  acid  in  his  blood.'  ^      It  is  also  well 
to  remember  that  the  hepatic  derangement  resulting  in  lithsemia 
may  exist   for   years   without    any   other   symptom   than    the 
frequent  deposit  of  lithates  or  lithic  acid  in  the  urine,  and  is 
then  curable  by  attention  to  diet  alone ;  but  that,  if  neglected, 
it  may  ultimately  develope  gout,  structural  disease  of  the  liver 
or  kidneys,  or  some  other  serious  malady.     Habitual  lithEemia 
ought,  therefore,  to  be  always  counteracted,  and,  from  what  has 
been  already  stated,  it  seems  clear  that  the  foods  mainly  to  be 
avoided  are  saccharine  and  oleaginous  articles,  and  especially 
cooked  dishes  containing  both  of  these  substances.  Patients  with 
litliEemia  ought  always  to  avoid  made-up  or  highly  seasoned 
dishes.     In  severe  cases,  potatoes,  rice,  sago,  and  fruits  may 
have  to  be  given  up,  and  even  bread  must  be  taken  in  modera- 
tion.    It  will  also  always  be  well  to  ascertain  if  the  lithsemia  be 
due  to  any  of  those  idiosyncrasies  in  virtue  of  which  particular 
articles  of  diet  are  apt  to  derange  the  liver.     In  most  cases  of 
lithsemia,  a  diet  consisting  chiefly  of  stale  bread,  plainly  cooked 
mutton,  white  fish,  poultry,  game,  eggs,  a  moderate  amount  of 
vegetables,  and  weak  tea,  cocoa,  or  coffee  answers  best ;  while 
in  others  the  patient  enjoys  best  health  on  a  diet  composed  of 
milk,  farinacea,  vegetables,  eggs,  and  occasionally  fish.     The 
quantity,  as  well  as  the  quality,  of  the  food  must  be  attended 
to.     Habitual  lithsemia  often  results  from  the   patient  taking 
more  food  than  can  be  converted  into  tissue  or  disintegrated  in 
the  liver.     As  Dr.  Bence  Jones  has  observed  with  regard   to 
gout,  so  in  habitual  lithsemia,  '  a  minimum  of  albuminous  food 
should  be  taken,  in  order  to  produce  the  least  uric  acid ;  and  a 

1  Psychological  luquiries,  2nd  edit.  1855,  p.  76. 


6l6  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.    "    lect.  xti. 

minimum  of  carbonaceous  food,  in  order  to  allow  the  uric  acid 
to  be  oxydised  as  much  as  possible.'  ^  In  obstinate  cases  the 
patient  may  be  advised  to  take  his  principal  meal  in  the  morn- 
ing, when  the  digestive  powers  are  strongest. 

Still  greater  caution  is  necessary  in  all  forms  of  lithsemia  as 
to  alcoholic  stimulants.  Malt  liquors,  port  wine,  champagne, 
and  many  other  wines  ought  to  be  strictly  prohibited.  Claret, 
or  a  small  quantity  of  spirit  largely  diluted,  as  a  rule,  answers 
best;  but  even  these  should  be  taken  sparingly,  and  many 
patients  do  best  with  no  stimulants  at  all.  This  is  not  the 
occasion  to  discuss  whether  alcohol  is  necessary  for  the  nutri- 
tion of  the  body  in  persons  subjected  to  much  mental  or  bodily 
toil,  or  whether,  taking  the  masses  in  all  walks  of  life,  the 
standard  of  health  would  be  better  maintained  by  teetotal 
habits  or  by  a  moderate  use  of  alcohol.  What  I  desire  now  to 
insist  upon  is,  that  alcoholic  drinks  in  quantities  usually 
regarded  as  compatible  with,  if  not  conducive  to,  health,  and 
far  short  of  what  are  necessary  to  affect  the  brain,  in  many 
persons  undermine  the  foundations  of  health  by  deranging  the 
liver ;  and  that  to  some  individuals  even  very  small  quantities 
are  injurious.  In  persons  who  have  been  indulging  largely, 
the  risk  of  a  sudden  withdrawal  of  stimulants  is  less,  I  believe, 
than  is  commonly  imagined.  Unless  there  be  evidence  of  a 
very  weak  heart,  which  itself  may  be  the  result  of  alcohol,  the 
only  unpleasant  efPccts  of  sudden  and  complete  abstinence,  in 
my  experience,  have  been  sensations  of  sinking  at  the  epigas- 
trium and  craving  for  alcohol,  which  a  repetition  of  the  stimulus 
has  only  temporarily  relieved  and  has  rendered  more  persistent. 

2.  A  Free  Supply  of  Oxygen. — Next  to  careful  regulation  of 
diet,  this  is  the  most  important  object  to  be  aimed  at  in  the 
treatment  of  functional  derangement  of  the  liver,  and  especially 
in  that  Avhich  induces  imperfect  disintegration  of  albumen.  An 
excess  of  fresh  air,  indeed,  will  often  counteract  the  bad  effects  of 
too  large  a  quantity  of  food.  Although  recent  observations,  more 
especially  those  of  Parkes,  have  shown  that  the  common  impres- 
sion that  muscular  exercise  materially  increases  the  elimination 
of  nitrogen  from  the  body  is  erroneous,  there  can  be  no  doubt 
that  exercise  in  the  open  air  quickens  the  circulation  of  blood 
through  the  liver  in  the  manner  alrearly  explained  and  promotes 
oxydation,  and  that,  b}-^  thus  preventing  the  accumulation  in 
the  system  of  the  imperfectly  oxydised  products  of  albumen,  it 

'   Op.  cit.  p.  142. 


LECT.  XVI,  TREATMENT.  617 

operates  beneficially  in  the  treatment  of  functional  derangement 
of  the  liver  attended  by  lithsemia.  The  observations  of  Beneke 
and  other  authorities  have  shown  that  sea-air  is  an  oxydising- 
agent  of  great  power,  and  that  nitrogenous  and  sulphur-holding 
tissues  more  rapidly  disintegrate  under  its  influence.^  Accord- 
ingly we  find  that  many  patients  with  hepatic  de.\angementand 
litliEemia  derive  immense  benefit  from  residence  at  the  seaside 
and  sea-bathing,  although  unfortunately  the  good  effects  of 
sea-air  are  sometimes  more  than  counterbalanced  by  unhealthy 
lodgings  or  improper  and  badly  cooked  food. 

3.  Diluents. — The  free  use  of  diluents,  such  as  soda  and 
seltzer  waters,  is  also  useful,  as  they  help  to  eliminate  from  the 
system  the  morbid  products  of  disintegration.  Many  patients 
also  with  lithscmia  derive  great  benefit  from  drinking  half  a 
pint  of  cold  water,  or  of  some  alkaline  water,  while  dressing  in 
the  morning  and  before  going  to  bed. 

4.  Baths. — In  all  cases  of  litheemia  and  gout  the  action  of 
the  skin  ought  to  be  maintained  by  frequent  bathing  or  ablu- 
tions of  the  entire  body  with  tepid  water  and  soap.  Cold 
baths  are  often  objectionable  from  inducing  muscular  or  gouty 
pains,  or  internal  congestions. 

5.  Aperients  ;  Cholagogues. — In  a  large  number  of  cases  of 
functional  derangement  of  the  liver  great  advantage  is  derived 
from  the  frequent  use  of  aperient  medicines,  whether  there  be  a 
tendency  to  constipation  or  not.  Aperients  bring  away  not 
merely  bile,  but  the  products  of  disintegration  contained  in  the 
fluid  circulating  between  the  liver  and  bowel  prior  to  their  fur- 
ther elaboration  and  elimination  by  the  lungs  and  kidneys. 
Saline  aperients,  from  the  promptness  of  their  action  and  the 
large  quantity  of  watery  exhalation  from  the  bowel  which  they 
induce,  are  among  the  best  for  the  purpose  now  mentioned. 
Eecourse  is  usually  had  to  the  sulphate  of  magnesia  (Epsom  salt), 
the  sulphate  of  soda  (Grlauber  salt),  the  tartrate  of  potash  and 
soda  (Rochelle  salt),  or  the  phosphate  of  soda,^  or  to  various 
combinations  of  these  salts  with  chloride  of  sodium,  carbonate  of 
soda,  and  other  alkaline  salts,  such  as  are  found  in  the  mineral 
waters  of  Carlsbarl,  Friedrichshall,  Plillna,  Harrogate,  or  Chelten- 
ham, or  in  the  recently  discovered  Hungarian  spring,  Hunjadi 

'  Parkes  on  Urine,  1860,  pp,  115,  129. 

-  Profesf-or  Rutherford  informs  me  tlmt  he  has  found  the  sulphate  of  soda  and 
the  phosphate  of  soda  to  be  powerful  excitants  of  the  biliary  secretion  in  dogs,  but 
the  sulphate  of  magnesia  to  have  no  eifect  at  all. 


6l8  FUNCTIONAL    DEEANGEMENTS    OF    THE    LIVEE.        xect.  xtt. 

Janes.  Daily  experience  shows  tlie  great  benefit  derived  by 
patients  with  lithsemia  from  a  course  of  one  or  other  of  these 
mineral  springs,  or  from  some  artificial  imitation  of  them,  all  of 
which  are  best  taken  with  warm  water  and  in  the  morning 
fasting.  All  of  these  salts  have  little  or  no  affinity  for  animal  tex- 
tures, so  that  they  excite  few  changes  in  them  ;  they  cause  very 
little  irritation  of  the  mucousmembraneof  the  bowel,  and  do  not 
excite  peristalsis,  so  that  they  purge  without  producing  griping 
or  pain.  They  act  apparently  by  preventing  the  reabsorption 
of  the  fluid  which  is  constantly  being  exhaled  from  the  blood- 
vessels into  the  bowel. 

There  are  certain  other  aperients  which  have  long  enjoyed 
a  great  reputation  for  promoting  the  secretion  and  discharge  of 
bile,  and  otherwise  acting  beneficially  in  derangements  of  the 
liver,  and  which  have  accordingly  been  designated  Gholagogues. 
Among  these  remedies  mercury  and  its  preparations  hold  a 
pre-eminent  place.  At  the  present  day  mercury  has  lost  much 
of  its  former  reputation  as  a  cholagogue  and  alterative,  and 
there  is  much  difference  of  opinion  as  to  its  power  over  the 
liver.  The  practical  physician  gives  a  dose  of  calomel,  finds  the 
quantity  of  bile  in  the  motions  greatly  increased,  and  his 
patient's  state  much  improved;  and  he  argues  that  the  liver 
has  been  stimulated  by  the  mercury  to  an  increased  secretion 
of  bile,  and  that  to  this  cause  his  patient's  improvement  must 
be  ascribed.  The  physiologist,  on  the  other  hand,  ties  the 
common  bile-duct  in  one  of  the  lower  animals,  produces  a 
fistulous  opening  into  the  gall-bladder,  and  then  finds  that 
calomel  has  no  effect  on,  if  it  do  not  diminish,  the  amount  of 
bile  that  drains  away  through  the  fistula.  It  may  interest 
some  who  are  present  if  I  refer  briefly  to  the  principal  of  these 
experiments. 

Kolliker  and  Mliller,  in  1855,  tried  the  eff'ects  of  calomel 
upon  the  secretion  of  bile  in  a  dog  with  a  biliary  fistula.  The 
results  were  somewhat  contradictory.  Once  the  bile  seemed  to 
be  increased,  and  twice  it  seemed  to  be  diminished,  by  the 
administration  of  calomel.^ 

Of  four  expeiMments  made  in  1858  on  a  dog  with  a  biliary 
fistula.  Dr.  George  Scott  found  that  in  all  the  administration  of 
large  doses  of  calomel  was  followed  by  a  diminution  of  fluid  bile 
and  of  bile-solids.'^ 

'  Wui-zburg  Verhiiiullungeii,  Ld.  v.  1855,  s.  231. 
2  Bcale's  Archives  of  Medicine,  1858,  vol.  i.p.  209. 


r-BCT.   XVI, 


TREATMENT.  619 


In  the  same  year  (1858),  Dr.  Mosler  made  similar  experi- 
ments upon  two  dogs  with  biliary  fistulfe.  Tlie  administration 
of  calomel  was  not  followed  by  any  increase  of  bile,  nor  could 
mercury  be  detected  in  the  biliary  secretion.^ 

Ten  years  later  (1868),  a  committee  of  the  British  Medical 
Association,  with  Professor  Hughes  Bennett  of  Edinburgh  as 
chairman,  made  a  number  of  similar  experiments  on  dogs,  and 
came  to  the  conclusion  that  '  mercury  did  not  increase  the  flow 
of  bile,  but  rather  diminished  it.'  ^ 

Next  in  order  (1873)  come  the  experiments  of  Dr.  Eohrig  of 
Kreuznach,  made  in  the  Pa-thological  Institute  of  Vienna.  He 
found  that,  although  large  doses  of  calomel  did  seem  to  increase 
somewhat  the  secretion  of  bile,  its  power  to  do  so  was  inferior 
to  that  of  croton  oil,  colocynth,  jalap,  aloes,  rhubarb,  senna, 
and  sulphate  of  magnesia,  the  cholagogue  power  of  these  drugs 
diminishing  very  much  in  the  order  in  which  they  have  now  been 
enumerated,  and  calomel  standing  at  the  bottom  of  the  scale.^ 

The  most  recent  experiments  are  those  of  Profesor  Ruther- 
ford and  M.  Vignal  on  four  different  dogs  during  fasting.  In 
three  the  secretion  of  bile  was  diminished,  and  in  one  it  was 
ascertained  that  not  only  the  total  quantity,  but  the  percentage 
of  solids,  was  reduced.  In  the  fourth  case  the  quantity  of  bile 
was  increased,  but  there  were  reasons  for  believing  that  the 
increase  was  not  due  to  the  calomel.* 

These  results  of  experiments  upon  the  lower  animals  have 
added  greatly  to  the  discredit  previously  thrown  upon  mercury 
by  its  failure,  when  brought  to  the  test  of  accurate  clinical 
observation,  to  absorb  plastic  lymph  in  most  forms  of  inflamma- 
tion ;  and  some  eminent  physicians  are  even  of  opinion  that 
mercury  and  its  preparations  ought  to  be  erased  from  our 
Pharmacopoeia.'''  On  the  other  hand,  it  has  been  fairly  objected 
that  the  results  of  experiments  with  mercury  upon  dogs  do  not 
warrant  conclusions  as  to  its  effects  upon  man  ;  and  even  grant- 
ing that  in  man  mercury  does  not  increase  the  quantity  of  bile 
secreted  by  the  liver  in  health,  it  does  not  follow  that  in  disease 
there  may  not  be  some  condition  adverse  to  the  formation  of 
bile,  which  mercury  may  have  the  power  of  removing.     Much, 

J  VirchoVs  Archir,  1858,  Bd.  xiii.  s.  29. 

2  British  Medical  Journal,  1868,  vol.  ii.  pp.  78,  176,  191. 

3  Strieker's  JahrbiTch,  1873,  part  2. 

<  British  Medical  .Journal,  Nov.  13,  1875. 

*  See,  Bennett,  British  Medical  Journal,  18  68,  vol.  ii.  p.  176. 


620  FUNCTIONAL    DEKANGEMENTS    OF    TEE    LIVER.        i.ect.  xvi. 

however,  of  the  difference  of  opinion  between  the  physiologist 
and  the  practical  physician  may  be  reconciled  by  keeping  in 
mind  the  osmotic  circulation,  to  which  I  referred  in  my  first 
lecture  (p.  550),  as  constantly  going  on  between  the  intestinal 
contents  and  the  blood.  A  large  part  of  the  bile  secreted  by 
the  liver  and  thrown  into  the  bowel  is  constantly  being  re- 
absorbed, to  reach  the  liver  again  ;  and  accordingly,  when  tlie 
common  bile-duct  is  tied  and  a  fistulous  opening  into  the  gall- 
bladder established,  the  quantity  of  bile  which  escapes  from  the 
fistulous  Oldening  immediately  after  the  operation  is  much 
greater  than  at  any  time  subsequently  (SchiiBP).  Mercury  and 
allied  purgatives  produce  bilious  stools  by  irritating  the  upper 
part  of  the  bowel  and  sweeping  on  the  bile  before  there  is  time 
for  its  re-absorption.  The  fact  of  mercury  standing  at  the 
bottom  of  the  scale  of  cholagogues  in  Eohrig's  experiments  is 
accounted  for  by  its  surpassing  other  cholagogues  in  this  pro- 
perty ;  for  of  course  the  larger  the  quantity  of  bile  that  is  swept 
down  the  bowel,  the  less  is  re-absorbed  and  the  less  escapes 
from  a  biliary  fistula.  That  mercury  does  act  especiallj^  upon 
the  duodenum,  is  proved  not  merely  by  the  large  flow  of  bile 
which  follows  its  action,  but  by  the  fact  discovered  by  Eadzie- 
jewski,  that  leucin  and  tyrosin,  which  are  products  of  pancreatic 
digestion,  under  ordinary  circumstances  decomposed  in  the 
bowel,  appear  in  the  fseces  after  the  administration  of  mercurials. 
It  would  appear,  then,  that  mercury,  by  increasing  the  elimina- 
tion of  bile  and  lessening  the  amount  of  bile  and  of  other  pro- 
ducts of  disintegrated  albumen  circulating  with  it  in  the  portal 
blood,  is  after  all  a  true  cholagogue,  relieving  a  loaded  liver  far 
more  efPectually  than  if  it  acted  merel}^  by  stimulating  the  liver 
to  increased  secretion,  as  was  formerly  believed,  and  as  some 
authorities  still  maintain  ;  for  in  this  case  it  might  be  expected 
to  increase,  instead  of  diminish,  hepatic  congestion.'  It  is  not 
impossible,  also,  that  the  irritation  of  the  duodenum  by  calomel 
and  other  purgatives  may  be  reflected  to  the  gall-bladder,  and 
cause  it  to  contract  and  dischai'ge  its  contents,  and  thus 
account  in  part  for  the  increased  quantity  of  bile  in  the  stools. 
There  are  likewise,  I  believe,  grounds  for  believing  that, 
apart  from  its  increasing  the  discharge  of  bile  from  the  bowel, 
rnercmy  extrts  a  beneficial  action  in  many  functional  derange- 

'  TIii.-<  vicM'  MS  to  the  action  of  mercury  upon  tlic  liver  has  Loon  tiiught  Ly  me  in 
my  lectures  for  mfiny  yearf--,  and  vas  enunciateil  in  the  first  edition  of  my  Cliniciil 
Lectures  on  Diseases  of  the  Liver,  pulJished  in  1868,  pp.  126,  '609,  404. 


LECT,  XVI.  TEEATMENT.  62 1 

ments  of  tlie  liver,   in  whatever  way  this  is  to  be  explained. 
Patients  of  the  greatest  intelligence  suffering  from  hepatic  dis- 
orders constantly  declare,  that  they  derive  benefit  from  occa- 
sional or  repeated  doses  of  mercurials  which  no  other  medicine 
or  treatment  confers ;  and  the  scepticism  of  the  most  doubting 
physician  would,  I  believe,  be  removed,  should  he  unfortunately 
find  it  necessary  to  test  the  truth  of  their  statements  in  his  own 
person.    It  is  not  impossible  that  the  good  effects  of  mercury  on 
the  liver,  and  in  some  forms  of  inflammation,  may  be  due  to  its 
property  of  promoting   disintegration.      Mercury   appears  to 
have  the  power  of  rendering  effused  fibrin  less  cohesive,  and  so 
more  easily  removed  by  absorption,  than  it  otherwise  would  be.' 
Modern  physicians  of  high  standing,  and  little  likely  to   be 
accused  of  credulity  as  to  the  beneficial  action  of  drugs,  have 
thought  that  mercury  is  useful  in  croup,  by  causing  a  degrada- 
tion and  disintegration  of  the  plastic  membrane,  and  this  view 
would  explain  why  it  is  that  mercury  is  always  injurious  in 
persons  of  scrofulous  constitution.      If  this  view  be  correct,  it 
seems  also  not  improbable  that  mercury,   which  from  experi- 
ments "-  we  know  to  reach  the  liver,  may  under  certain  circum- 
stances act  beneficially  by  promoting,  or  in  some  way  influen- 
cing, the  disintegration  of  albumen.     The  remarkable  effect  of 
mercury  on  constitutional  syphilis  perhaps  admits  of  a  similar 
explanation.     The   effect   of    mercury   on   the    elimination    of 
nitrogen  by  the  kidneys  has  still  to  be  investigated.     But  in 
whatever  way  it  is  to  be  explained,  the  clinical  proofs  of  the 
efficacy  of  mercury  in  certain  derangements  of  the  liver  are  to 
my  mind  overwhelming.     I  say  so  the  more  advisedly,  because 
I  was  taught  to  regard  mercury  as  a  remedy  worse  than  useless, 
not  only  in  hepatic  diseases  but  in  syphilis  j  it  cannot,  therefore, 
be  said  that  the  convictions  forced  upon  me  by  experience  are 
the  result  of  preconceived  opinions. 

Fodo])hyllin  is  a  remedy  which  seems  to  act  in  a  very  similar 
manner  to  mercury.  In  small  doses  it  has  been  shown  by 
Professor  Rutherford  to  increase  the  secretion  of  bile,  but  in 
decidedly  purgative  doses,  which  are  usually  necessary  to  relieve 
the  liver,  it  diminishes  the  biliary  secretion.  Dr.  Anstie's 
experiments  with  podophyllin  on  dogs  and  cats  show  that  it 
has  a  special  affinity  for  the  small  intestines,  and  especially  for 

1  Bence  Jones,  op.  cit.  p.  283. 

'■^  Autlienrietli  unci  Zeller  found  mercui-y  in  the  Liie  of  auiniiils  treated  with  mer- 
curial frictions.     (Budd,  op.  cit.  p.  bl.) 


622  FUNCTIOK'AL    DERANGEMENTS    OF    TFE    LIVER.        lect.  xvi. 

the  daodennm.  So  far  as  my  experience  goes,  it  is  less  certain 
in  its  action,  and  even  in  moderate  doses  more  likely  to  cause 
griping  and  mucous  stools,  than  the  preparations  of  mercury. 
It  is  a  good  substitute,  however,  for  mercury,  when  from  any 
cause  this  is  contraindicated. 

Colocynth,  Aloes,  Bhuharl,  Jala'p,  and  Senna  are  also  useful 
aperients  in  functional  derangements  of  the  liver  resulting  in 
lithsemia,  constipation,  or  deficient  excretion  of  bile.  Eohrig's 
experiments  on  dogs  seem  to  show  that  they  actually  increase 
the  amount  of  bile  secreted  by  the  liver :  while  from  those  of 
Professor  Rutherford  and  M.  Vignal  it  may  be  inferred  that, 
with  the  exception  of  senna,  they  are  cholagogues  of  consider- 
able power. 

I])ecacuanha,  which  I  have  already  referred  to  (p.  186),  as  a 
powerful  remedy  in  disease  of  the  liver,  I  have  also  often  found 
of  great  service  in  functional  disorder  of  the  gland,  and  from 
Professor  Eutherford's  experiments  on  dogs  it  would  appear  to 
be  one  of  the  most  powerful  known  cholagogues. 

Colchicum  has  also  been  found  by  experiment  to  be  a  chola- 
gogue  in  dogs,  and  in  man  it  is  a  useful  adjunct  to  other  aperients 
in  cases  of  liver-derangement  with  lithsemia.  According  to 
Dr.  Garrod,  it  '  may  often  be  given  with  advantage  to  gouty 
subjects  as  a  cholagogue  in  lieu  of  the  preparations  of  mercury,'  ^ 
which,  I  may  add,  are  often  contraindicated  in  chronic  gout  with 
renal  disease. 

'  Iridin/  obtained  from  the  root  of  the  Iris  versicolor, 
'  Euonymin,'  prepared  from  the  bark  of  the  Euonymus  atro- 
purpureus,  and  '  8anguinarin/  obtained  from  the  Sanguinaria 
plant,  have  a  considerable  reputation  in  America  as  cholagogues 
and  alteratives  of  the  hepatic  functions.  From  the  experiments 
of  Professor  Eutherford  also  they  appear  to  be  powerful  hepatic 
stimulants,  so  that  they  are  well  worthy  of  a  careful  trial  in  the 
human  subject.- 

With  these  remedies  we  may  include  TaraxacAun,  which  has 
long  been  thought  to  exercise  a  specific  action  upon  the  liver, 
but  which  has  been  proved  to  be  a  very  feeble  hepatic  stimulant, 
and  probably  acts  mainly  as  a  mild  aperient.  When  there  is  a 
tendency  to  constipation  it  may  be  advantageously  combined 
with  either  alkalies  or  mineral  acids. 

'  Op.  cit.  p.  410. 

*  Experiments  on  the  Biliary  Secretion  of  the  Dog.     (Joiirnal  of  Anatomy  and 
Physiology,  vol.  xi.  part  1,  1876.) 


LECT.  XVI.  TREATMENT.  623 

6.  Alkalies. — Next  to  aperients,  alkalies  are  the  most  useful 
drugs  in  the  treatment  of  functional  derangements  of  the  liver. 
In  litha3mia  and  in  many  of  the  symptoms  which  spring  from 
this  morbid  state,  the  greatest  benefit  is  often  derived  from  a 
course  of  alkalies — such  as  the  alkaline  salts  of  potash,  soda,  or 
litliia,  or  some  of  the  alkaline  mineral  waters,  such  as  those  of 
Yals,  Yichj,  or  Ems.  The  comparative  worth  of  the  different 
alkalies  for  neutralising  acids  varies  considerably.  One  grain 
of  carbonate  of  lithia  or  of  carbonate  of  ammonia  is  nearly 
equal  to  a  grain  and  a  half  of  carbonate  of  soda  or  two  grains 
of  carbonate  of  potash.  The  beneficial  effects  of  alkalies  in 
derangements  of  the  liver  are  not  due  to  their  neutralising 
acidity,  or  to  any  direct  action  upon  lithic  acid.  It  is,  in  fact,  in 
the  form  of  lithate  of  soda  that  lithic  acid  is  met  with  in  gouty 
persons.  Alkalies  seem  to  do  good  by  combating  the  ^^a-tho- 
logical  state  on  which  the  formation  of  lithic  acid  depends. 
They  are  believed  to  promote  oxydation,  and  thus  to  increase 
the  disintegration  of  albumen.  Dr.  Bence  Jones  tells  us  that 
in  the  body  as  well  as  out  of  it  alkalies  furnish  the  most  marked 
evidence  of  assisting  in  oxydising  actions.^  The  experiments  of 
Parkes  with  liquor  potassse  seemed  to  show  that  it  has  the 
power  of  increasing  the  disintegration  of  the  sulj)hur-holding 
materials  of  the  body.  The  effect  of  its  administration  was  to 
increase  the  amount  of  sulphuric  acid  and  also  of  urea  in  the 
urine ;  although,  with  characteristic  caution,  Parkes  adds  that 
the  increase  of  urea  as  the  result  of  the  potash  was  rendered 
probable,  rather  thaii  proved,  by  his  experiments,^  From  ex- 
periments on  dogs  with  biliary  fistulse,  Nasse  was  led  to  the 
conclusion  that  carbonate  of  soda  taken  with  the  food  di- 
minished greatly  the  secretion  of  bile ;  ^  and  a  similar  result 
has  been  observed  by  Eohrig  to  follow  the  introduction  of  the 
same  salt  into  the  intestine  or  the  veins ;  the  diminution 
affected  the  solids  as  well  as  the  water  of  the  bile,  and 
especially  the  biliary  salts.  Nasse  also  found  that  after  taking 
two  drachms  of  carbonate  of  soda  the  urine  (human)  was  very 
rich  in  hippuric  acid.  The  only  inference  at  present  to  be 
drawn  from  these  experiments  is,  that  alkalies  exert  a  power- 
ful influence  over  the  chemical  changes  going  on  in  the  liver. 
When  alkalies  are  employed  in  lithsemia,  it  is  well  to  suspend 
their  use  occasionally,  as  they  are  apt,  when  long  continued,  to 

'  Op.  cit.  p.  280.  2  On  the  Urine,  1860,  p.  151. 

3  Arcliiv  fiir  Wissenscb.  Heilkiui'le,  18G4,  Bd.  \\.  p.  508. 


624  FUNCTIONAL    DERANGEMENTS    OF    THE    LIVER.         lect.  xvi. 

derange  tlie  gastric  digestion  ;  but  in  cases  wliere  tliey  are 
strongly  indicated  tliey  are  better  tolerated  than  is  usually 
thought.  In  the  fifth  volume  of  the  Medico-Chirurgieal  Trans- 
actions Dr.  Bostock  has  recorded  the  case  of  a  young  lady,  who 
for  months  took  carbonate  of  soda  to  the  amount  of  2^  oz.  daily. 
The  appetite  and  strength  were  much  improved ;  and  her 
blood,  instead  of  being  thin,  coagulated  firmly,  the  coagulum 
being  strongly  buffed  and  cupped. 

7.  Chlorine,  Iodine,  and  Bromine  are  closely  related  in  their 
chemical  jDroperties,  and  are  believed  to  promote  oxydation  in 
the  body  by  taking  hydrogen  from  water  and  liberating  oxygen. 
An  aqueous  solution  of  chlorine  is  of  service  in  certain  cases  of 
lithsemia  associated  with  general  debility ;  and  we  know  that 
the  various  salts  of  chlorine  enter  largely  into  the  composition 
of  the  mineral  waters  which  are  most  useful  in  hepatic  derange- 
ments. Bromide  of  potassium  will  reduce  certain  enlargements 
of  the  liver  and  spleen,  and  may  be  given  with  advantage  in 
cases  of  lithsemia  associated  with  congestion  of  the  liver  and 
want  of  sleep.  But  among  the  remedies  of  this  class  the 
chloride  of  ammonium  holds  a  pre-eminent  place.  It  has 
obtained  a  great  and  well- deserved  reputation  in  India]  and 
other  tropical  countries  for  the  treatment  of  hepatic  congestion  ; 
and  I  have  found  it  of  great  service  in  the  functional  derange- 
ment of  the  liver  attended  by  lithsemia.  Given  in  scruple  doses 
three  times  a  day,  it  acts  as  a  diaphoretic  and  diuretic  and 
exercises  a  powerful  influence  in  relieving  the  portal  circula- 
tion. It  is  not  oxydised,  but  passes  out  of  the  system  un- 
changed in  the  urine.  Professor  Rutherford  has  found  it  to 
have  no  effect  upon  the  bile-secretion  of  dogs;  but  according 
to  Booker's  experiments,^  it  increases  the  nitrogenous  solids  of 
the  urine;  the  mean  daily  increase  of  urea  under  its  use  he 
found  to  be  not  less  than  74  grains — a  quantity  indicating  a 
vast  augmentation  either  of  metamorphosis  or  of  elimination, 
but  from  its  beneficial  efifect  on  the  liver,  most  probably  of 
the  former.  Chloride  of  ammonium  has  also  this  advantage, 
that  it  may  be  combined  with  either  alkalies  or  mineral  acids. 
(See  also  Lecture  IV.,  p.  136.) 

8.  Mineral  Acids  are  employed  by  many  physicians  in  the 
treatment  of  functional  derangements  of  the  liver.  Nitric  acid 
especially  has  long  been  thought  to  have  the  power  of  augment- 
ing the  flow  of  bile ;  but  there  is  no   good  evidence  of  this, 

'  Parkcf,  op.  cit.  p.  165. 


LECT.  XVI.  TREATMENT.  625 

either  clinical  or  experimental.  Professor  Eutherford,  indeed, 
informs  me  that  nitro-muriatic  acid  has  no  eflPect  upon  the  bile- 
secretion  of  dogs.  According-  to  my  experience,  the  action  of 
mineral  acids  upon  the  liver  is  much  less  direct  than  that  of 
alkalies.  In  all  morbid  states  of  the  liver  attended  by  congestion 
and  in  most  cases  of  lithsemia  I  have  found  that  they  either  did 
no  good,  or  that  they  aggravated  the  symptoms.  They  may, 
hov^ever,  be  of  service  when  there  is  debility  and  v^ant  of  tone ; 
but  the  chief  good  vrhich  they  effect  is  probably  that  of  im- 
proving the  gastric  digestion.  In  some  cases,  both  acids  and 
alkalies  may  be  given  advantageously — the  alkalies  before,  and 
the  acids  after,  a  meal. 

9.  Tonics. — Clinical  experience  shows  that,  notwithstanding 
the  existence  of  debility  and  anaemia,  tonic  remedies  are  apt  to 
disagree  in  many  cases  of  functional  derangement  of  the  liver. 
This  remark  applies  especially  to  the  functional  derangement 
resulting  in  lithsemia.  I  have  repeatedly  known  patients  in 
this  state  improve  at  once  on  substituting  abstinence  from 
alcohol,  with  aperients,  blue  pill,  alkalies  and  careful  regula- 
tion of  diet,  for  quinine,  iron,  the  mineral  acids  and  stimulants  ; 
the  strength,  flesh,  and  colour  returning  under  what  at  first 
sight  might  have  appeared  a  lowering  treatment.  Different 
opinions  have  been  expressed  with  regard  to  the  utility  of  iron 
in  chronic  gout.  According  to  Dr.  Bence  Jones,  iron  is  one  of 
the  two  most  potent  remedies  we  possess  for  indirectly  promot- 
ing oxydation  in  gout  as  well  as  in  other  maladies  ;'  whereas,  in 
Dr.  Garrod's  opinion,  the  preparations  of  iron  are  very  likely, 
when  indiscriminately  given  to  gouty  subjects,  to  excite  a 
paroxysm  of  the  disease,  and  for  the  most  part  are  contraindi- 
cated.^  My  experience  coincides  with  that  of  Dr.  Garrod ;  and 
in  simple  lithsemia  I  have  constantly  known  iron  to  increase 
the  tendency  to  deposits  of  lithates  in  the  urine,  constipate  the 
bowels,  and  aggravate  any  symptoms  from  which  the  patient 
may  have  previous!}^  suffered.  As  a  rule,  also,  I  have  found 
that  patients  with  chronic  gout  or  with  Jitheemia  do  not  tolerate 
even  small  doses  of  quinine.  From  some  careful  experiments 
made  by  Dr.  Eanke  of  Munich,  quinine  appears  to  have  the 
power  of  diminishing  the  amount  of  litliic  acid  in  the  urine.^ 
The  experiments  were  made  on  three  persons,  and  the  results 
were  uniform.  The  effect  continued  for  about  two  days  after 
a  single  dose  of  20   gr. ;  and  there  was  no  evidence  of  any 

'  Op.  cit.  pp.  143,  279.  2  Op.  cit.  p.  4o3.  =  Parkes,  op.  cit.  p.  167. 

S    S 


626  FUNCTIONAL   DERANGEMENTS   OF    THE    LIVER.        LEtx.  xti. 

increased  excretion  after  the  effect  of  the  quinine  had  passed  off, 
so  that  probably  the  quinine  acted  by  lessening  the  formation 
of  litliic  acid  in  the  liver,  or  by  substituting*  some  other  substance 
for  it.  From  these  experiments  it  might  be  inferred  that  quinine 
and  bark  should  be  of  essential  service  in  chronic  gout  and  in 
lithsemia,  but  this  inference  is  opposed  to  clinical  experience.^ 

When  tonics  are  given  in  lithsemia,  gentian,  chiretta,  cas- 
carilla  and  serpentaria  are  preferable  to  quinine  and  other 
preparations  of  bark.  The  best  preparations  of  iron  are  the 
reduced  iron,  the  citrate  of  iron,  or  the  tartrate  of  iron  and 
potash ;  these  preparations  are  sometimes  advantageously  com- 
bined with  alkalies  and  saline  aperients.  In  many  cases,  whether 
attended  by  flatulence  or  not,  I  have  seen  great  relief  follow  the 
use  of  small  doses  of  nux  vomica  or  strj^chnia.  In  cases  of 
lithsemia  attended  by  great  nervous  prostration  I  have  also 
seen  advantage  from  the  use  of  phosphorus  in  doses  of  one- 
thirtieth  of  a  grain  three  times  a  day.  The  lithates  have  dis- 
appeared from  the  urine  and  all  the  symptoms  have  improved. 
In  some  of  these  cases  the  circumstances  seemed  to  leave  no 
doubt  that  the  improvement  was  due  to  the  phosphorus. 
Many  patients  also  with  lithsemia  who  cannot  take  iron  derive 
benefit  from  arsenic,  which  has  long  been  known  to  be  of  ser- 
vice in  some  of  the  complications  of  gout. 

10.  Opium  and  its  preparations  are  contraindicated  in  most 
functional  derangements  of  the  liver,  and  particularly  when 
there  is  evidence  of  lithsemia.  Opium  impedes  elimination  both 
by  the  bowels  and  kidneys  and  also  appears  to  check  the  disin- 
tegrative processes  which  go  on  in  the  liver.  It  is  generally  be- 
lieved to  diminish  the  amount  of  bile  secreted  by  the  liver ; 
and  this  view  is  favoured  by  the  light-coloured  stools  which 
often  follow  its  use.  The  result,  however,  of  Eohrig's 
experiments  on  animals  with  biliary  fistulse  was  to  show  that 
opium  increased  the  secretion  of  bile  instead  of  diminishing 
it ;  so  that  probably  the  discharge  of  bile  from  the  liver  is 
only  temporarily  suspended  by  a  similar  influence  on  the 
coats  of  the  bile-ducts  to  that  which  opium  exerts  on  the  coats 
of  the  bowel.  Be  this  as  it  may,  there  can  be  no  doubt  that 
opium  constipates  the  bowels,  favours  portal  congestion,  and 
checks  the  elimination,  not  only  of  bile,  but  of  the  products  of 
disintegration  which  go  on  in  the  liver.     The  experiments  of 

'  Eiinke's  experiments  have  l)ecn  reyjeated  by  Dr.  Garrod,  wlio  found  that  quinine 
did  not  materially  influence  the  excretion  of  lithic  acid.     Garrod,  op.  cit.  p.  451. 


lECT.  XVI.  TREATMENT,  62/ 

Booker^  and  clinical  experience  alike  show  that  opium  impedes 
the  elimination  of  the  nitrogenous  solids  of  the  urine,  and  that 
dangerous  and  even  fatal  consequences  ensue  from  its  employ- 
ment in  structural  diseases  of  the  kidneys.  These  considera- 
tions explain  why  in  hepatic  derangement  attended  by  lithsemia 
opium  is  contraindicated  for  the  relief  of  pain,  sleeplessness,  or 
other  symptoms  for  which  it  is  commonly  prescribed. 

On  the  other  hand,  it  is  not  a  little  remarkable,  as  confirma- 
tory of  the  supposed  antagonism  between  gout  and  diabetes,  to 
which  I  have  already  referred  (p.  559),  that  in  the  functional  de- 
rangement of  the  liver  which  exists  in  the  latter  disease  opium 
is  tolerated  in  large  doses,  and  is  often  of  signal  service  in 
checking  the  formation  of  sugar.^  Its  good  effect  is  probably 
in  great  measure  due  to  some  influence  on  the  vaso-motor  nerves 
of  the  hepatic  vessels,  a  reflex  paralysis  of  which  we  have  found 
to  be  one  of  the  causes  of  diabetes. 

In  bringing  these  lectures  to  a  close,  I  beg  to  tender  to  you, 
Mr.  President,  and  to  the  Censors'  Board,  my  thanks  for  the 
honour  you  have  done  me  in  appointing  me  to  deliver  them. 
I  am  very  sensible  of  their  manifold  imperfections,  and  in 
apology  can  only  plead  a  multiplicity  of  other  engagements 
during  the  brief  period  allotted  to  their  preparation.  I  am 
well  satisfied,  however,  as  to  the  great  importance  of  the  sub- 
ject which  I  have  brought  before  your  notice,  and  that  it  is  one 
worthy  of  more  attention  from  the  Fellows  and  Members  of 
this  College,  and  from  the  profession  generally,  than  it  has  yet 
received.  The  day,  I  believe,  will  come  when,  with  a  more 
perfect  knowledge  than  we  now  possess  of  the  healthy  functions 
and  of  the  signs  of  functional  derangement  of  the  liver,  we 
shall  be  enabled  to  prevent,  or  to  arrest  at  their  commencement, 
many  of  the  most  serious  ailments  to  which  mankind  are  liable, 
and  thereby  to  add  another  chapter  to  the  volume  of  Preventive 
Medicine. 

'  Partes,  op.  cit.  p.  167. 

2  This  is  no  new  discovery.  Sixty-three  years  ago,  Sir  Benjamin  Brodie  com- 
municated to  the  Koyal  Medical  and  Chirurgical  Society  a  case  of  diabetes  treated 
with  opium.  Twenty-four  grains  of  opium  were  taken  in  the  day  with  the  effect  of 
reducing  the  urine  from  twenty-five  to  seven  pints,  but  without  any  of  the  usual  effects 
of  opium.     Medico-Chirurgical  Transactions,  vol.  v.  p.  236. 


s  s  2 


APPENDIX. 


Page  75.  Since  Lecture  III.  passed  tkrougli  the  press,  tlie  following 
case  of  hydatid  of  the  liver,  treated  successfully  by  paracentesis,  has 
come  under  my  notice. 

Case  OLXXVII. — Hydatid  of  Liver — Paracentesis — Recovery. 

William  0 ,  aged  31,  bootmaker,  admitted  into  St.  Thomas  sHosp.  Dec. 

5,  1876.  Habits  temperate ;  taken  no  stimulants  for  14  years.  Never  out  of 
England.  As  a  rule  digestion  good,  and  no  pain  after  food ;  but  for  a  year  or 
more  liable  at  intervals  of  a  week  or  month  to  attacks  of  flatulence  and  vomit- 
ing, usually  in  evening.  A  week  ago  first  noticed  a  swelling  in  right  hj'pochon- 
drium,  where  for  two  or  three  weeks  before  there  had  been  slight  pain.  Up  to 
this  time  followed  work.     Tumour  had  enlarged  slightly. 

On  admission  there  was  a  roimded,  smooth,  elastic,  painless  tumour  in 
epigastric  and  right  hypochondriac  regions,  causing  ribs  to  bulge  outwards,  and 
throwing  forwards  belly  of  rectus,  evidently  connected  with  liver.  Lower 
margin  of  timiom-  reached  to  umbilicus,  and  hepatic  dulness  in  r.  m.  1.,  including 
tumoiu-,  measured  9  in. ;  girth  of  r.  chest,  2  in.  below  nipple,  Yi\  in. ;  of  left,  15| 
in.  Slight  dull  pain  in  hepatic  region.  AU  other  organs  healthy.  Tongue 
coated  ;  appetite  bad  ;  bowels  regular.     P.  84 ;  temp,  normal. 

Dec.  18. — Paracentesis  with  fine  trocar;  5  oz.  of  fluid  drawn  off,  clear, 
sp.  gr.  1009 ;  much  chlorides,  but  not  a  trace  of  albumen  ;  no  echinococci.  Some 
hours  after  operation  patient  had  a  severe  attack  of  abdominal  pain,  and  temp, 
rose  from  98°  to  101-2°.  Pain  was  relieved  at  once  by  subcutaneous  injection  of 
morphia  gr.  ^.  Next  day  felt  quite  well,  but  temp,  varied  from  101-2°  to  102-6°. 
On  14th,  temp,  normal  and  ap.  good.  After  this  had  no  bad  symptom ;  and 
when  patient  left  hospital  on  Dec.  23,  tiunom'  could  not  be  felt,  and  girth  on  two 
sides  of  chest  equal. 

Tage  134.  Among  the  blood-poisons  causing  congestive  enlargement 
of  the  liver,  special  attention  ought  to  have  been  directed  to  syphilis. 
Both  the  liver  and  the  spleen  are  not  unfrequently  found  to  be  greatly 
enlarged  in  children  who  are  the  subjects  of  inherited  syphilis,  and  that  this 
enlargement  is  not  waxy,  and  in  all  probability  congestive,  is  shown  by 
the  rajDidity  and  completeness  with  which  it  often  disappears  under 
treatment,  or  independently.^     A  similar  enlargement  is  occasionally 

•  See  Brit.  Med.  .rourn,  1877,  i.  170. 


630  APPENDIX. 

met  Tvith  in  adults  in  tLe  secondary  stage  of  syphilis,  sometimes  in 
conjunction  with  catarrhal  jaundice.     (See  pp.  153,  157.) 

Page  144.  Case  LII. — Jan.  9,  1877.     Captain  M continues  in  excellent 

health,  and  has  applied  for  a  command  in  the  Pacific.  Gained  flesh;  girth  at 
umbilicus  30  in. ;  hver  smaller ;  dulness  in  r.  m.  1.  5^  in. 

Page  150.  Case  LVII. — Jan.  13, 1877.     Mrs.  R is  muchhetter  ;  gained 

much  flesh,  and  has  heen  about  and  attending  to  business  in  her  husband's  (a 
baker)  shop.  Liver  smaller.  No  periostitic  pains,  but  a  node  on  right  ulna. 
Catamenia  appeared  a  few  days  ago,  the  first  time  for  two  years. 

Pages  142  and  283.  Case  CLXXVIII.  is  the  one  referred  to  in 
Lect.  ly.  of  interstitial  hepatitis  resulting  from  a  chill.  I  am  indebted 
for  the  particulars  to  Dr.  Wilson  Fox,  under  whose  care  the  patient  was. 
In  Case  CLXXIX,,  where  the  hepatitis  went  onto  cirrhotic  contraction, 
the  disease  also  probably  originated  in  a  chill.  The  case  was  also  in- 
teresting  from  the  early  age  of  the  patient  (see  pp.  282-300). 
Frerichs  records  the  case  of  a  boy  aged  10,  in  whom  cirrhotic  con- 
traction of  the  liver  also  appeared  to  originate  from  a  chill  in  bathing.^ 

Case  CLXXVIII. — Interstitial  Hepatitis  resulting  from  a  Chill. 

J.  C ,  45,  adm.  into  University  College  IIosp.,  with  following  history  and 

symptoms. 

For  4  years  a  cab-driver;  before  that  had  driven  omnibus  for  16  years. 
Man'ied  27  years ;  4  children  living.  Had  lived  all  his  life  in  London  and  been 
of  temperate  habits ;  had  taken  1^  pint  of  beer,  and  quarter  of  a  pint  of  claret, 
or  a  glass  of  port  wine,  daily ;  only  very  rarely  taken  a  little  rum.  Strong 
corroborative  evidence  that  this  statement  was  reliable.  No  hereditary  tendency 
to  disease,  except  that  father  had  been  habitually  intoxicated  and  had  died  in  a 
fit  at  55.  I'atient's  previous  health  had  been  always  good  ;  never  had  syphilis, 
dyspepsia,  nor  morning  sickness.  Two  months  before  admission  had  got  wet 
through  and  remained  thus  on  his  cab  for  six  or  seven  hours.  On  coming  home 
felt  chilly,  and  during  night  had  pains  in  legs  and  ankles,  which  next  morning 
were  swollen.  Next  evening  felt  worse  and  had  pains  in  shoulders,  across  chest, 
and  in  region  of  liver.  He  lost  appetite,  flesh,  and  strength,  and  vomited  occa- 
sionally, and  for  a  fortnight  before  admission  he  had  vomited  all  solid  food.  A 
few  days  before  admission  had  an  attack  of  severe  pain  in  epigastrium,  with  a 
feeling  of  constriction  stretching  round  to  loins  and  lasting  24  hours.  Bowels 
had  been  regidar.  From  beginning  of  illness  had  been  confined  to  house,  and 
mostly  to  bed. 

On  admission,  chief  complaint  was  of  pain  in  hepatic  region,  vomiting,  and 
weakness.  Considerable  emaciation  and  pallor ;  icteric  tint  of  conjunctivae, 
but  no  distinct  jaundice  and  no  anasarca.  Appetite  poor;  thirst;  tongue 
furred  ;  bowels  regular.  Slight  fulness  in  epigastrium ;  no  ascites.  Hepatic 
dulness  extended  in  r.  m.  1.  from  sixth  rib  to  2  in.  below  costal  arch,  and  in 
middle  line  to  within  two  fingers'  breadth  of  nmbilicus ;  edge  firm  and  rounded ; 
surface  smooth,  firm,  and  tender.  Spleen  not  perceptible  below  false  ribs;  but 
its  dulness  reached  upwards  to  eightli  interspace  in  axilla. 

•  Dis.  of  Liver,  Syil.  Sue.  od.  ii.  GO. 


APPENDIX.  63 1 

During  most  of  time  he  was  in  hospital,  urine  of  normal  quantity  ;  sp.  gr. 
1010  to  10:^0  ;  no  albumen ;  no  sugar  ;  always  traces  of  bile-pigment,  and  on 
one  occasion  crystals  of  leucin  and  tyrosin  found  after  evaporation.  Towards 
close  it  was  scanty,  high-coloured,  and  deposited  much  lithates.  Pulse  varied 
from  80  to  100.  On  some  days  temp,  normal,  but  as  a  rule  pyrexia,  temp, 
varying  from  99-5°  to  101-5°.  No  periodicity  in  rise  of  temperature.  Occa- 
sional perspiration,  but  not  profuse,  and  never  rigors.  Three  weeks  after  admis- 
sion patient  had  an  attack  of  plem-opneumonia  in  lower  half  of  left  lung,  which 
subsided  in  a  fortniglit,  and  during  which  temp,  rose  to  103°.  Pain  and  tender- 
ness in  hepatic  region  persisted,  varying  in  intensity,  but  never  very  severe. 
Vomiting  also  occurred  at  times,  and  vomited  matters  were  occasionally  streaked 
Avith  blood.  Three  weeks  after  admission  diarrhoea  set  in  ;  it  was  easily  checked, 
but  recurred  at  intervals ;  on  two  occasions  stools  contained  a  little  blood  ;  no 
piles.  Moderate  epistaxis  about  same  time  as  haemorrhage  from  bowels.  Within 
a  month  of  admission  there  was  increased  bulging  of  liver  above  umbilicus, 
and  hepatic  dulness  extended  about  an  inch  higher  up  into  chest.  On  two 
occasions  an  aspirator  was  passed  deeply  into  different  portions  of  liver  without 
result.  Epigastric  veins  became  more  prominent,  but  at  no  time  was  there 
ascites.  Towards  close  diarrhcBa  became  more  frequent  and  obstinate,  and  at 
last  was  uncontrollable  by  remedies.  Jaimdice  increased,  but  never  intense  ; 
stools  pale.     Patient  died  exhausted  six  months  after  admission  into  hospital. 

Autopsy. — Liver  much  enlarged,  extending  4^  in.  below  ensiform  cartilage, 
and  2  in.  below  ribs  in  r.  m.  1.,  and  upwards  as  high  as  fourth  intercostal  space 
in  fi'ont ;  weight  85  oz.  ;  outer  surface  slightly  granular.  Hepatic  tissue  much 
indurated,  at  some  places  white,  glistening,  and  replaced  by  fibrous  tissue,  at 
others  showing  a  great  increase  of  fibrous  tissue  between  the  lobides.  Branches 
of  portal  vein  dilated.  Bile  entered  duodenum  freely.  Spleen  enlarged  and 
indurated.  Stomach  and  intestines  much  congested.  Lungs  emphysematous, 
witli  some  old  calcareous  nodules.     Other  organs  healthy. 

Case  OLXXIX. — Interstitial  Hepatitis  resulting  from   Chill,  and  endinff  in 
Cirrhotic  Contraction,  in  a  Child  aged  12. 

On  Sept.  22,  1876,  I  was  consulted  respecting  Miss  Helen  F.,  aged  12,  and 
1  received  following  particulars  of  her  case  from  her  mother  and  from  Dr.  Lewis 
Mackenzie  of  Tiverton,  imder  whose  care  she  had  been.  Gout  on  both  sides  of 
family.  From  infancy  patient's  liver  had  been  sluggish.  For  two  or  three 
weeks  at  a  time  motions  would  be  white  and  skin  slightly  yellow.  At  age  of  six, 
after  bathing  in  sea,  had  been  seized  with  severe  abdominal  pain,  lasting  twelve 
hours,  and  making  her  call  out.  For  three  weeks  after  had  been  poorly,  with 
white  stools  &c.  After  this  had  usual  health  till  autmnn  of  1874,  when 
decided  jaundice  appeared  for  first  time.  It  came  on  slowly,  and  was  attended 
by  some  pain  for  about  two  days.  Abdomen  became  very  protuberant,  with 
large  veins  coursing  over  it,  and  liver  reached  down  almost  to  pubes.  Kept 
bed  for  a  day  or  two  now  and  then.  After  three  or  foiu'  months  general  con- 
dition improved  ;  but  ever  since  had  been  thin ;  temper  irritable,  appetite 
capricious,  bowels  loose,  urine  very  scanty,  dark,  and  loaded  with  lithates,  and 
complexion  of  a  greenish  hue.  For  weeks  stools  would  be  clay-colom-ed,  with- 
out any  trace  of  bile.  Since  March  1876  motions  had  often  contained  much 
mucus  and  bright  red  blood.  Dr.  M.,  who  first  saw  her  in  March  1876,  found 
spleen  enlarged,  but  hepatic  dulness  diminished.     At  time  of  visit  to  me  liver 


632  APPENDIX. 

not  enlarged ;  spleen  projected  2^  in.  beyond  ribs ;  sliglit  jaundice,  but  no 
ascites  ;  heart  and  lungs  normal ;  no  albuminuria  ;  bowels  loose,  less  blood  ;  no 
Tomiting ;  teeth  decaj-ed  ;  no  evidence  of  syphilis  nor  of  taking  vdne  or  spirits  '■> 
very  thin  and  weak,  but  in  last  few  weeks  general  condition  had  improved. 

I  wi'ote  to  Dr.  M.  as  follows  :  '  Miss  F.'s  case  is  certainly  an  imusual  one,  but 
from  the  history  I  think  there  can  be  little  doubt  that  she  has  some  form  of 
chronic  interstitial  hepatitis  resulting  in  portal  obstruction.  The  absence  of  the 
usual  cause  seems  to  negative  true  cirrhosis,  nor  is  there  tinj  evidence  that  the 
hepatitis  is  syphilitic.  I  am  inclined  to  attach  importance  to  the  attack  of 
severe  abdominal  pain  after  bathing  six  years  ago,  as  indicating  the  origin  of  the 
malady  in  a  chiU.  But  although  the  cause  is  obscure,  the  condition  of  the 
liver,  I  fancy,  is  very  much  this:  thickening  of  capsule,  with  bands  of  fibrous 
tissue  passing  into  interior  and  obliterating  many  of  branches  of  portal  vein.' 

On  Dec.  12,  1876,  INIiss  F.  died.  For  three  weeks  before  death  she  was 
very  ill.  Symptoms  were :  diarrhoea  with  haemorrhage ;  pulse  120,  rising  at 
last  to  140;  temp,  at  fii-st  102-3°,  falling  at  last  to  95°;  breath  oflFensively 
sweet,  like  recently  opened  liver ;  delirium  and  maniacal  excitement,  and 
subsequently  irregular  breathing,  stupor,  and  coma. 

Autopsy  by  Dr.  Mackenzie. — Liver  small  and  rounded ;  weighed  only  16  oz.  ; 
puckered  and  irregular  on  surface.  Capsule  thickened  ;  tissue  firm  and  dense, 
and  pervaded  everywhere  by  bands  of  fibrous  tissue.  Spleen  enlarged.  Lower 
portion  of  intestines  much  congested,  and  mucous  membrane  covered  here  and 
there  with  small  extravasations.  Mesenteric  veins  gorged  with  blood.  Other 
organs  normal. 

Fage  344.  In  Case  CLXXX.  it  appears  to  me  that  the  most 
probable  explanation  of  the  jaundice  in  the  first  instance  was  the  presence 
of  distomata  in  the  bile-ducts,  and  that  the  development  of  the  small 
amount  of  cancer  found  in  the  duodenum  and  portal  lymphatics  was 
contemporaneous  with  the  rapid  emaciation,  ascites  and  severe  pain, 
which  set  in  five  or  six  months  before  death.  From  what  we  know  of 
other  cases  it  is  probable  that  in  the  early  stage  of  the  patient's  illness 
there  were  a  large  number  of  these  distomata  in  the  liver,  and  very 
possibly  it  was  distomata  which  the  patient  observed  in  the  stools 
while  at  Malvern  in  June  1874.  Distomata  in  the  common  bile-duct 
might  have  excited  a  local  peritonitis  in  the  portal  fissure,  leading  ulti- 
mately to  obliteration  of  the  duct.  It  has  been  often  observed  that 
they  cause  great  thickening  and  induration  of  the  walls  of  the  bile- 
ducts.  The  Fasciola  hepatica,  though  very  common  in  the  livers  of 
sheep  and  cattle,  is  very  rare  in  the  human  liver.  Possibly  it  may 
have  often  been  overlooked.  According  to  Cobbold,  it  has  been  met 
with  in  the  human  subject  in  only  about  twenty  cases.' 

Case  CLXXX. — Jaundiee  from  Distomata  in  Bile-ducts,  folloived  by  Cancer  of 
Duodenum  and  Lymphatics  in  Ported  Fissure — Ascites  and  Death. 

On  May  8,  1874,  I  saw  Mr.  Charles  B.,  aged  30,  at  the  request  of  Dr.  J.  T, 
AVilliams  of  Barrow-in-Furness.     lie  was  of  temperate  habits,  and  had  enjoyed 

'  Lect.  on  Practical  Helminthology,  1872,  p.  143. 


APPENDIX.  62,3 

excellent  health  until  five  months  before,  when  he  became  jaundiced  after 
overwork  and  worry.  Jaundice  came  on  gradually,  with  loss  of  appetite  and 
lowness  of  spirits,  but  without  pain  or  sickness.  Skin  had  been  intenselj^  itchy 
and  bowels  irregular;  motions  light  and  mine  dark.  Since  jaundice,  but  not 
before,  had  lost  flesh  at  rate  of  a  pound  a  week.  No  family  history  of  malig- 
nant disease  ;  father  had  been  killed ;  mother  had  died  at  73 ;  one  brother  bad 
died  insane. 

I  noted  that  he  was  a  small  spare  man,  very  nervous  and  excitable,  and 
deeply  jaundiced.  Chief  complaints  were  weakness,  loss  of  appetite,  and  a 
coppery  taste  in  mouth.  Liver  slightly  enlarged ;  vertical  dulness  in  r.  m.  1. 
measured  4f  in.  But  what  struck  me  most  was  a  slight,  but  distinct,  bulging 
forwards  of  costal  cartilages  to  right  of  lower  end  of  sternum;  over  this  part 
was  slight  tenderness,  but  nothing  like  fluctuation. 

The  nature  of  the  case  was  evidently  obscure ;  but,  in  writing  to  Dr.  W.,  I 
discussed  fully  the  possibilit}-  of  its  being  cancer,  hydatid,  or  catarrhal  jaundice. 
Cancer  appeared  excluded  hj  patient's  age,  the  absence  of  usual  symptoms,  and 
especially  by  fact  that  patient  had  been  in  good  health  and  not  losing  flesh 
before  jaundice  appeared.  On  the  whole  I  was  inclined  to  think  that,  notwith- 
standing its  duration,  the  case  would  turn  out  to  be  one  of  catarrhal  jaundice, 
although  the  bulging  referred  to  suggested  the  possibility  of  there  being  a 
hydacid. 

I  never  saw  patient  again,  but  on  several  occasions  I  heard  of  him  from 
Dr.  W,  On  June  18, 1874, 1  heard  that  while  at  Malvern,  about  a  fortnight  before. 
he  had  felt  something  '  crack '  in  region  of  liver,  and  next  morning  stool  had 
contained  '  about  a  tablespoonful  of  little  lumps  of  gum  and  small  bladders. 
These  Dr.  W.  imagined  might  be  hydatids,  but  he  had  no  opportunity  of  seeing 
any.  Stools  varied  much,  sometimes  of  colour  and  consistence  of  putty,  at 
others  almost  natural  in  colour.  Itchiness  and  bulging  to  right  of  sternum  less. 
Lost  about  7  lbs.  more  in  flesh.  Jaundice  about  the  same.  On  Oct.  13,  1874, 
the  report  was  as  follows :  For  some  weeks  jaundice  more  intense,  with  in- 
creased irritability  of  skin.  Stools  very  light  and  mine  very  dark.  No  change 
in  bulging  of  right  lower  ribs.  Appetite  good,  and  more  able  to  do  his  work. 
No  pain  nor  uneasiness  in  region  of  liver  at  any  time.  On  Feb.  3,  1876,  the 
report  was  :  '  In  man}"-  respects  better  ;  has  improved  in  strength,  weight,  and 
appetite,  and,  though  usually  very  depressed  in  spirits,  follows  his  employment 
as  a  clerk  to  the  entire  satisfaction  of  his  employers.  Motion  snatural  in  colour 
and  consistence.  No  irritation  of  skin,  which  is  less  yellow,  but  somewhat 
bronzed  like  that  of  Addison's  disease.  No  appreciable  bulging  of  right  costal 
cartilages.'  He  remained  much  in  same  state  and  continued  at  his  post  imtil 
.August  1876,  when  he  noticed  that  he  was  beginning  to  increase  in  size  around 
waist.  The  swelling,  which  was  due  to  ascites,  increased  slowly  and  was 
attended  by  intense  pain  at  lower  end  of  sternum  and  rapid  emaciation.  Faeces 
were  again  light  and  often  contained  much  mucus ;  urine  loaded  with  bile. 
Towards  end  of  December  Dr.  W.  tapped  abdomen  and  drew  off  nearly 
two  gallons  of  yellow  serous  fluid ;  after  this,  pain  was  much  relieved,  but 
patient  got  weaker  and  thinner,  and  died  on  January  26,  1877.  After  death  it 
Avas  ascertained  that  Mr.  B.  had  been  particularly  fond  of  uncooked  shell-fish, 
especiallj'  whelks  and  mussels,  but  there  was  no  evidence  of  his  having  eaten 
freshwater  molluscs. 

Autopsy. — Not  more  than  1^  pint  of  fluid  in  peritoneum.  Dr.  W.  was  good 
enough  to  forward  to  me  liver,  duodenum,  and  kidneys.     Liver  slightly  granular 


634  APPENDIX. 

on  surface ;  substance  dense,  "with  increase  of  fibrous  tissue  between  lobules. 
Common  bile-duct  and  cystic  duct  completely  obliterated  by  cicatricial  con- 
traction of  fibrous  tissue  in  portal  fissure.  Two  or  three  lymphatic  glands  in 
portal  fissure  enlarged  to  about  size  of  hazel-nuts  and  compressing  trunk  of 
portal  vein.  Gall-bladder  greatly  distended,  containing  fully  10  oz.  of 
colourless,  serous,  flaky  fluid.  Bile-ducts  in  interior  of  liver  moderately 
dilated ;  and  one  of  them  contained  a  fine  specimen  of  Distoma  (Fasciola 
hepatica)  ;  ^  ducts  were  carefully  washed  out,  but  only  the  one  specimen  could 
be  found.  Mucous  membrane  of  duodenum,  not  far  from  orifice  of  bile-duct> 
contained  a  circular  somewhat  elevated  plate  of  morbid  deposit,  about  size  of  a 
shilling.  This  deposit  was  not  ulcerated  and  did  not  extend  into  muscular  coat ; 
but  both  it  and  enlarged  glands  in  portal  fissure  were  ascertained  by  Dr.  Green- 
field to  be  cancerous.  No  evidence  of  cancer  elsewhere  in  body.  Left  kidney 
expanded  into  a  large  cyst  which  ruptured  in  removal ;  nature  of  this  cyst  not 
ascertained. 

'  The  specimen  is  in  the  Museum  of  St.  Thomas's  Hospital. 


">i»E!lTr\ 


V 


'Ajiti'f 


INDEX. 


Abbreviations :  L.  =  Liver, 


ABD 


J.  =  Jaundice. 
of  Liver. 


F.U.L.  =  Functional  Derangements 


ASC 


ABDOMINAL  parietes,  abnormal 
states  of,  in  relation  to  diseases  of 
L.,  14 

abscess  in,  15 

fistula  into  gall-bladder,  501,  514 

hydatid  of  L.,  64 

Abscess  between  diaphragm  and  liver,  13 

—  in  abdominal  parietes,  15 

—  of  gall-bladder,  186,  504,  514,  524 

—  of    L.        See    Pycemic    and    Troincal 

Abscess 

subdivision      into      pysemic     and 

tropical,  164,  181 
Aching  in  limbs,  584 
Aiids  in  hepatic  derangement,  624 
Active  ascites,  445,  471 
Acute  peritonitis,  442,  462 
Acute  yellow  atrophy  of  liver,  259,  407 

•  cases  of,  269 

causes  of,  265 

■  —  clinical  characters,  259 

pathology  of,  267,  408 

rarity  of,  259 

temperature  in,  262 

treatment  of,  267 

Addison's  disease,  distinction  of  bronzing 

from  J.,  312 

■  symptoms  not  due  to  destruction  of 

supra-renal  capsules,  231 
Age,  influence  on  size  of  liver,  7 
Ague.     See  Malarious  Fevers 
Albumen,  destroyed  in  liver,  537,  541 
Albuminuria   in  acute  atrophy  of  liver, 

263 

ascites,  451 

cirrhosis,  282 

congestion  of  liver,  133 

F.D.L.,  573 

malarious  fevers,  397 

waxy  L.,  34 

j^ellow  fever,  396 

Alcohol,  a  cause  of  acute  atrophy  of  L,,  265 
—  —  cirrhosis,  141,  283,  301 


Alcohol,   a  cause  of  congestion  of  liver, 

133 

— • fatty  liver,  51 

■ —  F.D.L.,  667,  609,|616 

■  —  interstitial  hepatitis,  141 

tropical  abscess,  181 

Alcoholic  dyspepsia,  277 

Alkalies,  623 

Aloes,  622 

Alveolar  hydatid.     See  Multilocular 

Amyloid  L.     See  Waxy 

Anaemia  from  fatty  L.,  49 

F.D.L.,  579 

• J.,  321 

renal  disease,  50,  448 

waxy  liver,  34 

Aneurism,    abdominal,    a    cause    of    J., 

356 

—  of  aorta,  diagnosis  from  hydatid,  20, 

60 
displacing  L.,  19 

—  of  hepatic  artery,  356,  431 

—  of  superior  mesenteric  artery,  357 
Angina  pectoris,  599 

Animal  poisons,  a  cause  of  J.,  404 
Antimony,  a  cause  of  J.,  406 
Antiseptics  in   suppurating  hydatid,  82, 

96 
— •  —  tropical  abscess,  191 
Aortic  valve  disease,  576,  599 
Aperients  in  F.D.L.,  617 
Appendix    vermiformis,   gall-stones    in, 

496 
ulceration  of,  a   cause  of  pysemic 

hepatitis,  166,  171 
Appetite  in  F.D.L.,  580 
Arteries,  exaggerated  pulsation  in,  598 
Ascaris  lumbricoides.     See  Lumbricus 
Ascites,  active,  445,  471 

—  causes  of,  447 

—  diagnosis  from  distended  bladder,  441, 

459 
hydatid,  439 


6^6 


INDEX. 


ASC 

Ascites,    diagnosis    from    ovarian    cvst, 
435 

pregnant  uterus,  442 

renal  cyst,  440 

—  displacing  L.,  13,  254 

—  fiom  acute  peritonitis,  445 

—  —  cancer  of  L.,  210,  454 

peritoneum,  445,  465 

portal  glands,  479 

chronic  atrophy  of  L.,  279,  283 

chronic  peritonitis,  444,  462 

cirrhosis,  279,  453,  476 

colloid  disease,  446,  480 

congestion  of  L.,  133 

diseases  of  chest,  146,  284,  449,  475 

kidneys,  448,  473 

—  L.,  279,  283,  450 

hydatid,  [<Q 

interstitial  hepatitis,  140,  454,  475 

peri-hepatitis,  284,  454 

portal  obstruction,  450 

—  —  pysemic  abscess,  165 
simple  dropsy,  447 

thrombosis  of  portal  vein,  455 

tropical  aliscess,  184 

■ tubercle,  443,  469 

waxy  L.,  33,  453 

—  in  diagnosis  of  cause  of  J.,  432 

—  signs  of,  434 

—  treatment  of,  285,  487 

—  with  gall-stones,  509 
J.,  432 

Ascitic  fluid,  452 
Asthma,  pathology  of,  602 
Atheroma  of  arteries,  575,  599 
Atrophy  of  L.,  255 

acute,  259.     See  Acute  Atrophy 

chronic,  274 

red,  255,  276,  284 

simple,  255.  See  Simple  Atrophy 

— yellow,  259.    See  Acute  Atrophy 


BATH  of  nitro-muriatic  acid,  137 
Baths  in  F.D.L.,  617 
"Bile,  composition  of,  326,  542 

—  excessive  absorption,  a  cause  of  J.,  413 
secretion  a  cause  of  J.,  412 

—  in  blood  not  a  poi.son,  323,  559 

—  inspissated  in  ducts,  337 

—  quantity  secreted,  329,  545 

—  symptoms  of  deficient  excretion,  560 

—  uses,  551 

Bile-acids,  formed  in  liver,  326,  547 

in  urine,  a  test  of  cause  of  J.,  427 

their  eompo.vition,  326,  543 

Bile-ducts,  cancer  of,  352,  379,  389 

distomata  in,  344,  632 

gall-stono.M  in,  337,  488 

hydatids  in,  66,  109,  112,  343 

inflammation  of.  See  Ivflammaiion 


CAN 

Bile-ducts,  obstruction  of,  160,  336 

sacculus  of,  490 

tumours  in,  352,  379 

vilcers  in,  154,  350,  491 

Bile-pigment,  absorbed,  332,  549 

• composition  of,  543 

■ converted  into  urinai-y  pigment, 538 

derived  from  blood,  543 

in  inflammatory  exudations,  316 

milk,  316 

■ —  mucus,  316 

• sweat.  315 

—  tears,  316 

urine,  313 

not  preformed  in  blool,  326,  545 

test  for,  313 

Biliary  colic  from  gall-stones,  337 

h3'datids,  66,  116,  344 

ulcer  of  duodenum,  349 

—  fistulpe,  external,  501,  505,  514,  547 

internal,  497,  505,  507 

Bilious  headaches,  586 

Bitter  taste  in  F.D.L.,  580 

—  —  —  J.,  316 

Bladder,  urinary,  mistaken  for  ascites  or 

hydatid,  441,  459 
Blood-corpuscles,  white,  formed  in  L.,  536 
red  destroyed  in  L.,  538 

—  poisons  a  cause  of  acute  atrophy,  266 

• —  ■ congestion  of  L.,  134 

F.D.L.,  614 

J.,  394 

Boils  in  F.D.L..  606 

J.,  318 

Bones  diseased,  a  cause  of  waxy  L.,  35, 

39 
Brain  in  J.,  314 

Bright's  disease,  pathology  of,  572 
Bromine,  624 
Bronchitis,  602 
Bronzing  from  Addison's  disease,  312 

sun,  312 

Burning  patches  in  palms  and  soles,  584 


CANCER,  cause  of  fatty  L.,  50 
waxy  L.,  36 

—  cells,  derived  from  liver-cells,  230 

—  colour  of  skin  in,  311 

—  pathology  of,  579,  613 
Cancer  of  bile-ducts,  352,  379,  389 
duodenum.  352,  382 

gall-bladder,  221,  526 

ghuids  in  portal  fissure,  479 

kidneys,  345 

L.,  208 

cases  of,  216,  378,  527 

causes  of,  212,  575 

clinical  characters,  208 

diagnosis  from  catarrh  of  bilo 

ducts,  153,  213 


INDEX. 


637 


CAN 

Cancer  of   L.,    diagnosis  from  cirrhosis, 

213,  299 
gall-stones,  213,  221,  371, 

— hydatid,  226 

— rnnltilocnlarliydatid,  21-1, 

'2i2 

spindle-cell  sarcoma,  23.') 

syphilitic  L.,  213 

waxy  L.,  212 

melanotic,  232 

treatment,  214 

without  symptoms,  208,  210 

pancreas,  345 

peritoneum,  445,  465 

rectum,  527 

stomach,  a   cause  of  pysemic   he- 
patitis, 166,  172 

Carbuncles  in  F.D.L.,  606 

J.,  318 

Catarrh  of  Lile-ducts.     See  Inflammation 

duodenum  and  stomach,  153 

Cerebral  symptoms  in  acute  atrophy  of 
L.,  262 

cirrhosis,  282,  530 

F.D.L.,  592 

J.,  322,  333 

treatment  of,  268,  415 

Chest-diseases,  influence  on  L.,  10.     See 
Heart  and  Lungs 

(Uiill,  a  cause  of  cirrhosis,  142,  630 

congestion  of  L.,  134 

interstitial  hepatitis,  142 

tropical  abscess,  181 

Chloride  of  ammonium  in  diseases  of  L., 

136,  187,  624 
Chlorine  in  F.D.L.,  624 
Chloroform,  a  cause  of  J.,  407 
Chlorosis,  distinction  from  J.,  311 
Cholagogues,  617 
Cholestearsemia,  323,  560 
Cholesterin,  323,  544 
Chordee,  604 
Chronic  atrophy  of  L.,  274,  409 

•  cases  of,  201,  475 

from  chill,  142,  631 

hypersemia,  274,  475 

peri-hepatitis,  275 

spirit-drinking,  283,  301 

syphilis,  275,  284 

treatment  of,  285 

varieties,  274,  283 

—  peritonitis,  444,  463 

Circulation  disordered  in  F.D.L.,  594 

Cirrhosisof  L.,  274.  409 

cases  of.  291,  476,  631 

causes  of,  282,  301,  575,  631 

clinical  characters,  277 

diagnosis  from  cancer,  213 

patliology,  274 

spurious,  275,  283 


DUO 

Cirrhosis  of  L.,  treatment,  285 

Cirrhotic  enlargement  of  L.,  140,  278 

Colchicum,  622 

Colic,  biliarv,  317,  485 

from  hydatid,  66,  116,  344 

—  duodenal,  349,  485 

—  intestinal,  484 

—  renal,  484 

Colloid  of  peritoneum,  446,  480 

Colocynth,  622 

Colon,  fgeces  in,  causing  J.,  14,  358 

simulating  enlargement  of  L , 

14 

—  fistulsB  with  gall-bladder,  498,  511 
Congenital  absence  of  Ijile-duct,  346,  3>7<5i 

—  malformations  of  L.,  7 
Congestion  of  L.,  131,  412,  425 

■  —  cases  of,  137 

causes,  133 

clinical  characters,  132 

•  treatment,  134 

— varieties,  133 

Constipation,  cause  of  J.,  358,  413 

—  from  F.D.L.,  581 
Constitutional  tendency  to  F.D.L.,  613^ 
Contractions  of  L.     See  Atrophy 

spurious,  253 

Convulsions  from  F.D.L.,  589 
Copaiba,  287 

Copper,  cause  of  J.,  406 

Corpulence,  554 

Cramps,  585 

Cystic  duct,  calculi  in,  339,  488,  525 

Cystin,  pathology  of,  569 

Cystitis,  603 

Cystosarcoma  of  L.   241 

Cysts,  simple,  in  L.,  242 


DEBILITY  in  J.,  321 
Diabetes,  pathology  of,  556' 
— -  with  atrophy  of  L.,  54 

hypertrophv,  54 

Diarrhoja  from  F.D.L.,  581 

J.,  317 

portal  obstruction,  145,  281 

waxy  disease,  35 

Diet,  cause  of  F.D.L.,  608 

—  cure  for  F.D.L.,  614 
Dihients  in  F.D.L.,  617 
Disintegration,  abnormal.  562 
Distomata  in  bile-ducts,  344,  632 
Double  vision,  588 

Dropsy  of  gall-bladder,  525 

peritoneum.     See  Ascites 

Duodenum,  cancer  of,  352.  382 

—  fistulfe  -with  gall-bladder,    497.    507» 

509 

—  inflammation  spreading  to  bile-due's, 

153,  345 
— -  ulcer  of,  cause  of  J.,  348,  376 


638 


INDEX. 


DUO 

Dxiodemim,  ulcer  of,  symptoms,  348,  485 
Dysentery,  cause  of  fatty  L.,  51 

—  pysemic  hepatitis,  166,  178 

• red  atrophy,  285 

tropical  abscess,  178 

waxy  L.,  35 

Dyspepsia,  cause  of  F.D.L.,  607 
J.,  317 

—  result  of  F.D.L.,  581 

—  simulating  disease  of  L.,  483 


ECHINOCOCCUS.     8ee  TcBiiia 
Eczema,  604 
Elimination,  abnormal,  559 
Emaciation  from  E.D.L.,  556 

J.,  317 

Emphysema  of  lungs,  eifeets  on  L.,  10 
Empyema,  effects  on  L.,  12,  16 
Endocarditis,  cause  of  pysemic  hepatitis, 

167 
Enlargements  of  gall-bladder,  161,  252, 

341,  488,  523 

L.,  2,  30 

rare  forms,  31,  235 

spurious,  7 

subdivision  of,  30 

with  J.,  30,  432 

without  J.,  30 

Enteric  fever  cause  of  J.,  401,  419 

Epidemic  J.,  402 

Epistaxis  in  diseases  of  L.,  44,  264,  280, 

320 
Epithelioma  of  L.,  241 
Eruptions  in  F.D.L.,  604 

J.,  318 

Ether,  cause  of  J.,  407 
Euonymin,  622 


F^CES.     See  Colon 
—  in  F.D.L.,  582 

J.,  317,  430 

Easciola  hepatica.     See  Dktomuta 
Fat  in  fasces,  317,  355 
Fatty  heart,  50 

—  L.,  48 

case,  53 

causes,  50,  575 

clinical  characters,  48 

treatment,  52 

—  kidneys,  50,  448 
1^'over.     Sec  Pyrexia 

Fibroid  nodules  in  L.     .See  Gummaia 
Fistulse  from  gall-stones,  496,  507,  547 

into  colon,  498,  511,  528 

pleura,  501 

—  _ portal  vein,  500,  521 

. small    intestine,    497,     507, 

509 
stomach,  497 


GAL 

Fistulse   from    gall-stones   into    urinary 
passages,  500 

vagina,  500 

■  —  through  abdominal  parietes, 

501,  514,  547 
Fistulse  from  hydatids,  64 
Fluke  of  L.     See  Disiomata 
Flutterings  of  heart,  594 
Functional  derangements  of  L.,  553 

causes,  607 

classification,  553 

treatment,  614 

Functions  of  L.,  532,  563 
Fungus  hsematodes  of  L.,  229 


GALL-BLADDER,  abscess  of,  514,  524 
cancer  of,  221,  526,  527 

— -  —  carbonate  of  lime  in,  308 
— -  —  dropsy  of,  525 

enlargements  of,  161,  262,  341,  488, 

523 

diagnosis  from  abscess  of  L.,  186 

hydatid,  59 

treatment,  504,  527 

gall-stones  in,  487,  504,  525 

inflammation  of,  161,  524 

• perforation  of,  496 

— •  —  ulceration  of,  491,  506 
Gall-stones,  cases  of,  271,  367,  506 

cause  of  acute  atrophy,  271 

colic,  337,  488 

fistulse,  372,  494,  496 

—  - — ■  ■ inflammation   of  bile-ducts, 

154,  159,  491 

■ peritonitis,  491,  496 

—  P3'8emic  hepatitis,   166,  173, 

491,  521 

causes  of,  341,  571 

diagnosis   from   cancer,    213,  22!, 

371,  374 

how  to  find  them  in  fseces,  342 

— •  —  in  appendix  vermiformis,  496 

common  duct,  337,  490,  523 

cystic  duct,  339,  488,  525 

duodenum,  494 

gall-bladder,  487,  504,  525 

lu'patic  duct,  488,  489 

ileum,  494,  504.  508 

portal  A'cin,  521 

sacculus  of  common  duet,  490, 

506 

large,  voided  per  aiium,  492 

obstructing  bile-duct,  336,  367 

—  • —  pathological  consequences,  159,487 
prognosis,  359,  504 

symptoms,  337,  487 

treatment,  360,  504 

vomited,  493,  497 

with  ascites,  509 

renal  calculi,  514,  571 


INDEX. 


639 


GAN 

Gangrpne  of  L.,  120 

Gin-drinkers'  L.,  274.     See  Cirrhosis.  . 

Glycocholic  acid,  326,  543  \ 

Glycogenic  function  of  L.,  534  | 
Gout,  canse  of  catarrh  of  bile-ducts,  153,    J 

i  56.  575  ! 

cirrhosis,  283,  575  i 

J.,  153,  156,  426,  575  ! 

—  conciirrenco  with  gall-stones,  342,  571    | 

—  pathology  of,  568 

Gouty  hepatitis,  575  ! 

—  phlebitis,  600  I 
Giimmata  in  L.,  141,  147  ; 
muscles,  149,  150  ' 


HAEMORRHAGES  from  portal  obstruc- 
tion, 140,  280,  295,  297 

—  in  acute  atrophy,  264 
F.D.L.,  583 

interstitial  hepatitis,  140 

J.,  320 

—  into  peritoneum  incancerof  L.,  227, 229 
Hseniorrhagie  J.,  259,  265 
HEemorrhoids,  pathology  of,  280,  583 
Headaches,  bilious,  586 
Heart-disease,  cause  of  ascites,  146,  283, 

306,  449,  475 

atrophy  of  L.,  274,  283,  306 

congestion  of  L.,  133,  137 

enlargement  of  L.,  133,  146 

F.D.L.,  607 

interstitial     hepatitis,    141, 

146,  274,-283 
pygemic  hepatitis,  167 

—  fatty,  60 

—  hydatids  in,  70 

—  irregularity  of,  from  F.D.L.,  594 
Heat  generated  in  L.,  541 
Hepatic  artery,  aneurism  of,  60,  356 
functions  of,  551 

—  dropsy,  279,  283,  450 

—  duct,  gall-stones  in,  489 

—  neuralgia,  485,  584 

—  pain.     See  Pain  in  L. 

Hepatitis.      See   Pymmic    and    Tropical 

Abscess  and  Peri-hepatitis 
— ■  interstitial,  139 

—  suppurative,  164 
Hereditary  J.,  426 

—  tendency  to  F.D.L.,  613 

Hydatid  of  L.  bursting  into  l)ile-duct,  66, 
109,  112,  114,  116,  343 

lungs,  62,  108,  109,  125 

pericardium,  63 

peritoneum,  63 

pleiu-ce,  62,  123,  124 

— portal  rein,  68 

stomach  or  intestine,  Qiy 

urinary  passages,  66 

vena  cava,  68 


Hydatid  of  L.  bursting  through  abdom. 
parietes,  64 

calcification  of  cyst,  62,  130 

cases  of,  87 

cause  of  marasmus,  68 

— pressure,  69 

loysemia,  69,  119,  167 

secondary  hydatids,  69 

causes  of,  70 

clinical  characters,  55 

diagnosis  from  abscess,  59,  186 

aneurism,  20,  60 

ascites,  122,  439 

cancer,  60,  129 

enlarged  gall-bladder,  59 

• ovarian  cyst,  61 

peritoneal  abscess,  23 

phantom  tumour,  26,  61 

—  • — •  pleuritic  effusion,  59 

renal  cyst,  27,  60,  440 

urinary  bladder,  460 

fluid  of,  61 

frequency  of,  55, 

• gangrene  of,  69 

inflammation  of,  69 

medicines  in,  71 

operation  by  electrolysis,  82 

fine    puncture    and    closing 

opening,  72,  87 

•  —  permanent  opening,  81,  97 

prevention  of,  70 

spontaneous  cure,  62,  130 

■  —  statistics  of  operations,  77 

— suppuration,  69,  97,  118 

terminations,  62 

■  treatment,  70 

Hydatid  vibration,  5Q 

Hydatids  compressing  spinal  cord,  70,  129 

ureter,  67,  125 

vena  cava,  69 

—  in  bile-ducts,  66,  114 
brain,  70 

—  —  gall-bladder,  66 

—  —  heart,  70 

—  ~  lungs,  69 

—  —  peritoneum,  69,  102,  106,  127 

—  multilocular,  214,  241 

—  multiple,  69,  99 
Hydronephrosis,  27,  60,  440 
Hydrops  cystidis  fellese,  525 
Hypertrophy  of  L.     See  Enlargements 

simple,  53 

Hypochondriasis,  591 


TCTERUS.     See  Jaundice 

A-     —  neonatorum,  312,  346,  433,  505 

Ileus  from  gall-stones,  494,  607 

Infill mmation  of  biliar}' passages,  152,  345 

cases,  155 

causes,  153 


640 


INDEX. 


INF 

luflammritiou  of  biliary  passages,  clinical 

characters,  152 

— , diagnosis  from  cancer,    1-53, 

213 

_ gall-stones,  3i6 

treatment,  154 

capsule  of  L.     See  Perl-hepatitis 

secreting    tissue.      See     Cirrhosis, 

Interstitial  hepatitis,  Pi/cemic-dxid 
Tropical  abscess 

gall-bladder,  161,  52-1: 

Inflammations,  local,  from  F.D.L.,  577 

Intercostal  neuralgia,  483 

Interstitial    hepatitis,     139.      See     also 

Cirrhosis 

cases,  142,  249,  475,  630 

■  causes.  141,  475,  630 

clinical  characters.  139 

treatment,  142.  285 

Intestinal  colic,  484 

Intestine,  ulceration  of  from  gall-stones. 

496 

—  ulcers  causing  pyemic  hepatitis,  163 
Iodine,  624 

Ipecacuanha,  136,  187,  622 
Iridin,  622 
Irritability,  592 
Itchiness.     See  Pruritus 

JALAP,  622 
Jaundice,  causes  of,  334 

—  concomitant  symptoms,  313 

—  definition  of,  310 

—  derivation  of  term,  310 

—  diagnosis  from  spurious  .1.,  311 
of  causes,  427 

—  feigned,  313 

—  from  acute  atropliy  of  L.,  260,  407 
aneurism,  356 

animal  poisons,  404 

antimony,  406  * 

cancer  of  bile-ducts,  352.  379,  389 

duodenum,  352,  382 

L.,  210 

catarrh  of  bile-ducts,  153,  345 

chloroform.  407 

cirrhosis,  281,  409 

congenital    absence    of  bile-ducts, 

346,  375 

congestion  of  L.,  132,  412,  425 

constipation,  358,  413 

copper,  40 G 

defective  oxygenation,  411 

di.stomata,  343,  632 

enlarged  glands  in  portal   fissun , 

353,  378,  390 
enteric  fever,  401,  419 

—  —  epidemic  causes,  402 
ether.  407 

—  —  excessive  absorption  of  bile,  41  :j 
secretion  of  bik',  412 


JAU 

Jaundice  from  faeces  in  bowels,  14,  358 

foreign  bodies  in  bile-ducts,  345 

gall-stones,  336,  367 

gout,  153,  156,  426,  575 

hydatii!s,    57,   66,    109,   112,    114. 

116,  343 

inflammation  of  bile-ducts,  153,  345 

duodenum,  153,  345 

— •  —  lymphoma,  353 

malarious  fevers,  396 

mercury,  406 

mineral  poisons,  405 

nervous  causes,  409 

obstruction  of  liile-ducts,  336 

^" cases  of,  367 

■  treatment,  360 

peri-hepatitis,  348 

phosphorus,  405 

pneumonia,  411,  424 

poisons  in  lAood,  394 

pressure  on  ducts,  353 

pyaemia,  404,  423 

pyfemic  hepatitis.  165 

relapsing  fever,  398 

scarlatina,  402,  421 

snake-bites,  404 

spasm  of  ducts,  351 

specific  fevers,  395 

•  stricture  of  ducts,  348,  350 

syphilis,  153,  157,  265 

tropical  abscess,  184 

tumours   of  bile-ducts,   352,    379, 

389 

duodenum,  352,  382 

kidneys,  355 

L.,  353 

omentum,  356 

ovaries.  359 

pancreas,  354,  374,  380 

post-peritoneal  glands,   356, 

392 

stomach,  354 

uterus,  359 

ulcers  of  bile-ducts.  350 

duodenum,  348,  376 

tj'phus,  399,  416 

—  —  waxy  L.,  33 

—  —  yellow  fever,  395 

—  liscmorrhagic,  259,  265 

—  hi^reditary,  426 

—  importance  of  recognising  causes,  310 

—  in   new-l)orn  children,  312,  346.   433, 

505 
— -  —  pregnancy,  358,  433 

—  independent   of  obstruction    of    bilc» 

ducts,  332,  394 

— —  cases,  415 

pathology,  325 

treatment,  41 4 

—  intensity,  313,  431 

—  intermittent,  431 


INDEX. 


641 


JAU 

Jaundice,  localities,  313 

—  malignant,  259 

—  prognosis  in,  359 

—  secretions  in,  315,  427,  430 

—  simple,  346 

—  spurious,  311 

—  table  of  causes,  334 

—  theory  of,  324 

—  treatment,  360,  414 

—  typhoid,  259,  395,  415 

—  with  ascites,  432 

cerebral  symptoms,  433 

pain,  431 

xanthelasma,  318 


KIDNEY,  cancer  of,  222 
—  degeneration,  pathology  of,  572 

—  diseases  of  causing  dropsy,  448,  473 
not  causing  dropsy,  449 

—  large  cyst  of    simulating  ascites    or 

hydatid,  27,  60,  440 

—  tumours  of  causing  J.,  355 

displacing  L.,  14 

Kidneys  in  waxy  L.,  34 


LACING.     See  Tight  Lacing 
Lardaceous  L.     See  Waxy  L. 
Lassitude,  584 
Lead-colic,  484 

—  dusky  colour  of  skin  from,  311 
Lepra,  604 

Leucin  and  tyrosin,  their  indications.  263, 
534,  539,  563 

—  composition  of,  263,  563 

—  in  acute  atrophy,  263 
enteric  fever,  401 

■ — •  —  relapsing  fever,  399 

typhus,  400 

Leuksemia  with  atrophy  of  L.,  307 

hypertrophy  of  L.,  54 

Lichen  in  F.D.L.,  604 

J.,  318 

Lithsemia,  565 

Lithic  acid  formed  in  L.,  539 

indications  of  in  urine,  564 

Liver,  area  of  dulness,  4 

—  boundaries,  3 

—  contractions,  253 

—  dimensions,  2 

—  enlargements,  2,  30 

—  functional  disorders.     See  F.B.L, 

—  functions  of,  532,  553 

— -  organic  disease  cause  of  F.D.L,,  607 
result  of  F.D.L.,  575 

—  situation,  2 

—  symptoms  of  its  diseases,  1 
Lumbrici,  a  nucleus  of  gall-stones,  345 

—  in  bile-ducts,  345 


OME 

Lung,  disease  a  cause  of  congestion  of  L., 
133,  141,  274 

dropsy,  449 

F.D.L.,  607 

J.,  411 

—  hydatids  in,  69 

Lymphatic  enlargement  of  L.,  247 


MALARIA,   cause  of   acute   atrophv, 
266 

congestion  of  L,,  134 

J.,  396 

tropical  abscess,  181 

—  duskiness  of  skin  from,  311 
Malarious  fevers  cause  of  J.,  396 

waxy  L.,  36 

Malformations  of  L.,  7 
Malignant  J.,  259 

Mania  from  F.D.L,,  590 
Megrim,  584 
Melancholia,  591 
Melanotic  cancer  of  L.,  232 
Mercury,  action  in  diseases  of  L.,    135, 
618 

—  cause  of  J.,  406 

—  eflfect  on  secretion  of  bile,  135,  330, 

618 
Mesenteric  artery,  aneurism  of,  357 
Milk  in  J.,  316 

Mineral  poisons  cause  of  J.,  405 
Multilocular  hydatid  of  L.,  214,  241 
Myxoma  of  L.,  240 


FEVOUS  influences   cause  of  acute 
atrophy,  266 

biliary  colic,  613 

cancer,  613 

F.D.L.,  612 

J.,  409 

—  disorders  from  F.D.L.,  584 
Neuralgia,  hepatic,  485,  584 

—  intercostal,  483 
Nitromuriatic  acid  bath,  137 
Noises  in  ears,  590 

Nutrition  abnormal  from  F.D.L.,  554 


OBSTRUCTION  of  bile-duct,  160,  336 
cause    of    enlargement  of 

L.,  160 

J.,  161,  336 

—  cases  of,  162,  367 

causes  of,  336 

clinical  characters,  161,  336 

prognosis,  359 

treatment,  162,  360 

portal  vein,  277,  450,  551 

CEsophagus,  cancer  of,  258 
Omental  tumour  cause  of  J.,  356 


T  T 


12 


INDEX. 


OPI 

Opium  in  F.D.L.,  626 

Orchitis,  604 

Ovarian  cyst,  diagnosis  from  ascites,  435 

hydatid,  122,  439 

opening  into  rectum,  458 

—  tumour  cause  of  J.,  359 

displacing  L.,  13 

Oxalate  of  lime,  pathology  of,  569 
Oxaluria,  570 

Oxygen,  cure  for  F.D.L.,  616 

—  deficiency  of,  cause  of  F.D.L.,  610 
J.,  411 

Ozeena  cause  of -waxy  L.,  35,  44 


PAIN  in  liver,  482,  485,  584 
—  —  —  causes  of,  485,  583 

diagnosis  from  gastrodynia,  483 

interstitial  neuralgia,  483 

intestinal  colic,  484 

pleurisy,  483 

pleurodynia,  482 

•  renal  colic,  484 

varieties  of,  485 

• with  J.,  431 

Painful  enlargements  of  L.,  30,  131 
Painless  enlargements  of  L.,  30 
Palpitations,  694 
Pancreas,  tumour  of,  a  cause  of  J.,  35 1, 

374,  380,  381 
Paracentesis  in  abscess  of  L.,  187 
ascites,  rules  for,  288 

—  • successful,  142,  307,  590 

hydatid,  72 

Paralysis  from  F.D.L.,  590 
Paraplegia  from  hydatid,  70.  129 
Penis,  melanotic  cancer  of,  232 
Perforation  of  bowels  from  gall-stones,  496 

gall-bladder,  491 

Pericardium,  effects  of  effusion  into  on  L., 
11 

—  hepatic  abscess  opening  into,  190 

—  hydatid  opening  into,  63 

Peri -hepatitis,  cause  of  ascites,  284 

atrophy  of  L.,  275,  305 

obstruction  of  bile-duct,  346 

—  ciiusps  of,  486 

—  symptoms  of,  284,  486 

—  syphilitic,  18,  44,  141,  275,  455 

—  treatment,  289 
Peritoneum,  cancer  of,  445,  465 

—  colloid  of,  446 

—  dropsy  of,  447 
--  fluid  in,  434,  442 

encysted     between    L.     and    dia- 
phragm, 13,  23,  226,  298 

—  gas  in,  255 

—  haemorrhage  into,  227.  229 

—  hydatids  of,  69,  102,  106,  127 
Peritonitis,  acute,  442,  462 

—  cancerous,  445,  405 


PTR 

Peritonitis,  chronic,  444,  463 
from  aneurism,  20 

—  gall-stones,  491,  496 

—  tubercular,  443,  469 
Phantom  tumour  of  abdomen,  26,  61 
Phlebitis,  gouty,  600 

Phosphorus,  cause  of  catarrh  of  bile-ducts, 
154 

J.,  405 

Phthisis.     See  Ttihercle 

—  from  F.D.L.,  559 
Pigment-spots,  606 

Pleura,  efiusion  in,  diagnosis  from  hyda- 
tid, 59 
effect  on  L.,  10,  12,  16 

—  fistulas  into  bile-duct,  501 

—  hepatic  abscess  opening  into,  190 

—  hydatid  opening  into,  62,  123,  124 
Pleuritic  pain  simulating  hepatic,  483 
Pleurodynia  simulating  hepatic  pain,  482 
Pneumonia  cause  of  J.,  411,  424 

• —  effect  on  L.,  ]  0 

—  from  F.D.L.,  577 
Pneumothorax,  effect  on  L.,  10 
Podophyllin,  621 

Poisons.     See  Blood-poisons,  Animal  and 

Mineral  Poisons 
Portal   obstruction,    symptoms   of,    277 

450 

—  vein,  compression  of,  455 
diseases  of,  455,  551 

fistulfe  into  bile-ducts,  500,  521 

function  of,  551 

thrombosis  of,  455 

Pregnancy,  cause  of  acute  atrophy,  265 

J.,  433 

Pregnant  uterus,  diagnosis  from  ascites, 

442 
Pruritus  in  F.D.L.,  606 
J.,  318 

—  treatment,  366 

Psoas  abscess  displacing  L.,  18 
Psoriasis,  604 
Pulse  in  F.D.L.,  596 
J.,  320,  432 

—  intermitting,  causes  of,  596 
Purgatives  in  F.D.L.,  617 
Pyaemia  cause  of  .J.,  404,  423 

—  from  hydatid  of  L.,  69,  13  9,  120 
Pysemic  hepatitis,  164 

cases,  169 

—  —  causes,  166 

clinical  characters,  164 

in  the  tropics,  178 

treatment,  167 

Pyelitis  cause  of  pyaemic  hepatitis,  167 

—  friini  liydatid  tumours,  57,  125 
Pyrexia,  absence  of  in  hepatic  abscess, 

175,  202 

—  cause  of  F.D.L.,  608 

—  in  acute  atrophy,  262 


INDEX. 


643 


PTR 


Pyrexia  in  cancer  of  L.,  224 

gall-stones,  340 

—  —  interstitial  hepatitis,  139,  281 


RECTI  muscles,  rigidity  of,  simulating 
enlargement  of  L.,  15 
Eed  atrophy  of  L.,  255,  276,  284 
Relapsing  fever,  cause  of  J.,  398 
Renal  calculi,  pathology,  568 

—  —  with  gall-stones,  514,  571 

—  colic,  diagnosis  from  hepatic  pain,  484 

—  cyst  simulating  ascites  or  hydatid,  27, 

60,  440 
Rheumatism  from  F.  D.  L.,  678 

—  with  J.,  318 
Rhubarb,  622 

Rickets,  effect  of  on  dulness  of  liver,  8 
Right  axillary  line,  5 

—  dorsal  line,  5 

—  mammary  line,  4 


SANGUIFICATION  in  L.,  533 
Sanguinarin,  622 
Scarlatina  cause  of  J.,  266,  402,  421 
Senna,  622 
Simple  atrophy  of  L.,  256 

case,  258 

causes,  256 

symptoms,  257 

—  hypertrophy  of  L.,  53 

—  induration  of  L.,  275 

—  J.,  346 

Skin  in  F.D.L.,  604 

J.,  318 

Sleeplessness  from  F.  D.  L.,  590 
Snake-bites,  cause  of  J.,  404 
Spasmodic  stricture  of  bile-duct,  351 
Spindle-cell  sarcoma  of  L.,  235 
Spleen,  cancer  of,  222 

—  enlargraentfrom  portal  obstruction, !279 
syphilis,  629 

waxy  disease,  34,  147 

Spurious  ascites,  435 

—  cirrhosis,  275,  283 

—  contractions  of  L.,  253 

—  enlargements  of  L.,  7 

—  J.,  311 

—  pains,  of  L.,  482 

Stomach,  catarrh  of  spreading  to  bile- 
ducts,  153,  345 

—  fistulse  into  bile  passages,  372 
gall-bladder,  497 

—  gall-stones  discharged  by,  493 

—  hydatid  opening  into,  65 

—  tumours  of,  a  cause  of  J.,  354 

—  ulcers  of,  a  cause  of  fatty  L.,  51 

—  ■ peri-hepatitis,  275,  284 

■ —  pysemic  hepatitis,  166, 

170,  172 


TUB 

Stools.     See  Fceces 
Stricture  of  bile-ducts,  348   350 
Suppression  of  bile,  325,  326 
Suppuration  of  gall-1  (ladder,  186 

hydatid,  69,  97,  118 

Suppurative  inflammation  of  liver,  164 
Supra-renal  capsules,  cancer  of,  23 1 
Sweat  in  J.,  315 
Syphilis  cause  of  acute  atrophy,  265 

—  catarrh  of  bile-ducts,  153,  157 

congenital  absence  of  bile-ducts 

347 

congestion  of  L.,  629 

—  ■ gummata  m  L.,  141,  147 

interstitial  hepatitis,  141,   147 

213,  275,  284 

peri-hepatitis,  18,  141,  275,  455 

waxy  L.,  35 


T^NIA  echinococcus,  70 
Taraxacum,  622 
Taste,  bitter,  in  F.D.L.,  580 

J.,  316 

Taurocholie  acid,  326,  543 
Temperature.     See  Pyrexia 

—  in  abscess  of  L.,  175,  202 
— •  —  acute  atrophy,  262 

gall-stone  colic,  340 

J.,  319 

Throat,  catarrh  from  F.D.L  ,  602 
Thrombosis  from  F.D.L.,  578 

—  gouty,  600 

— •  of  portal  vein,  455 
Tight-lacing,  its  effect  on  L.,  8 
Tongue  in  F.D.L.,  580 
Tonics  in  F.D.L.,  625 
Torpor  of  L.,  413,  561 
Tropical  abscess  of  L.,  177 

cases  of,  192 

causes,  177,  185 

•  —  clinical  characters,  182 

diagnosis    from    abscess   of 

gall-bladder,  186 

hydatid,  59,  186 

pysemic  hepatitis,  186 

discharging  in  different  di- 
rections, 182 

into  bowel,  197 

through  lung,  196 

objections  to  pysemic  theorv 

17s  ^' 

-■ pathology,  I77 

puncture  of,  187 

arguments  for,  189 

objections  to,  189 

rules  for,  190 

■ —  treatment,  186 

without  pyrexia,  202 

Tubercle  cause  of  fatty  L.,36,  51 


644 


INDEX. 


TUB 

Tubercle  cause  of  Avaxy  L.,  36 

—  coexistence  with  cancer,  258 
-of  L.,  245 

Tubercular  peritonitis,  443,  4  69 

—  Toniicse cause  of  pysemic hepatitis,  IG7, 

176 
Tumours  between  diaphragm  an'l  L.,  13 

—  compressing  bile-ducts,  353 

—  in  bile-ducts,  352 

—  intra-thoracie,  effects  on  L.,  10 

—  of  kidney,  cause  of  J.,  355 
displacing  L.,  13 

—  of  omentum  cause  of  J.,  356 
displacing  L.,  13 

—  of  ovary  cause  of  J.,  359 
•  —  displacing  L.,  13 

—  of  pancreas  cause  of  J.,  354 

—  of  uterus  cause  of  J.,  359 

displacing  L.,  13 

Tympanites  simulating  atrophy  of  L.,  253 
Typhoid  fever.     See  Enteric 

—  J.,  259,  322 

—  state  in  F.D.L.,  692 

Typhus,  cause  of  acute  atrophy,  266 

J.,  399,  416 

Tyrosin.     See  Leucin 


TTLCERS  of  bile  ducts.     See  Bile-ducts 

U duodenum.     See  jDuochnnm 

intestines.     See  Intestine 

stomach.     See  Stomach 

Uraemia  from  E.D.L.,  539 

hydatid  tumour,  127 

Urea  formed  in  L.,  538,  540 
Ureter  compressed  by  hydatid,  57,  125 
Urethritis,  603 

Urinary   bladder    simulating    ascites   or 
hydatid,  441,  459 

—  organs,  symptoms  from  F.D.L.,  603 

—  passages,   fistulee    with    gall-bladd(  r, 

500 

—  pigment  from  bile-pigment,  538 

in  hepatic  disorders,  538 

Urine  in  acute  atrophy,  263 
cirrhosis,  282 

congestion  of  L.,  133 

contracted  kidney,  449 

fatty  kidney,  448 


TEL 

Urine  in  F.D.L.,  538 

gall-stone  colic,  341 

hepatic  dropsy,  451 

J.,  315,  427 

malarious  fevers,  396 

typhus,  400 

—  —  waxy  disease,  34,  449 
yellow  fevers,  396 

—  test  for  bile-acids  in,  427 

— ■ bile-pigment  in,  313 

Urticaria  in  F.D.L.,  605 
J.,  318 

Uterus.     See  Tumours 


YAGINA,    fistula    with    gall-bladder. 
500 
Vena  cfiva  inferior,  hydatid  opening  into, 

68 
pressure  on  by  hydatid,  69 

—  portse.     See  Portal  Vein 
Venous  thrombosis,  600 

Vision,  dimness  of,  in  F.D.L.,  588 

—  double  in  F.D.L.,  588 
Vitiligoidea.     See  Xanthelasma 


WAXY  L.,  31 

T  T cases  of,  39 

causes,  35 

clinical  characters,  31,  453 

diagnosis  from  cancer,  32,  47,  212, 

213 
—  —  nodulated  form,  32,  47 

■  pathology  of,  559 

prevention,  36 

treatment,  37 

Wine.     See  Alcohol 


XANTHELASMA,  247,  318,  370,  606 
Xanthin,  pathology  of,  569 
Xanthopsy  in  J.,  321 


YELLOW   atrophy   of   L.    See   Acute 
atrophy 

—  fever,  J.  in,  395 

—  vision  in  J.,  321 


liONDDN  :    PnlN'TKD     IIV 

SrOTTISWOODB    AND    CO.,    NM-.W-STllKKT    SQUAKK 

AND    PARI.IAMKXT    STREET 


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Clinical  lectures  on  di 


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